THE PRINCIPLES 



j>» 



PRACTICE OF MEDICINE 



SERIES OF ESSAYS 



BY 

JOHN W. HOOD, M.D. 



By the union of study and practice, we attain a knowledge of the profession. 



( 









PHILADELPHIA: 
THOMAS, COWPERTHWAIT & Co. 

> 1848. 






Entered, according to Act of Congress, in the year 1848, by 

John W. Hood, 

In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



Xing & Bairdj Printers, 9 George St. Philadelphia. 



SAMUEL JACKSON, M.D., 

Professor of the Institutes of Medicine in the University of Pennsylvania. 

AS 

A TOKEN OF ESTEEM 

FOR 

HIS TALENTS AND MERITED DISTINCTION; 
HIS AMITY AND MANX OTHER EXCELLENT QUALITIES, 

THESE ES SAYS 

ARE AFFECTIONATELY DEDICATED 
BY 

HIS ARDENT FRIEND, 

THE AUTHOR. 



CONTENTS 



Anatomical arrangement and configuration of the Body, .... 9 

Chronic diseases of the Viscera of the Abdomen, 30 

Strumous Habit, 55 

Fever, 96 

Displacement of the Womb, 127 

Asiatic Cholera, 160 

Mechanical Agents, 174 

Reducible Hernia, 192 

Hemorrhoids, or Piles, 202 

Gout, 217 

The Tongue, 252 

Appendix, 258 



PBEFACE. 



In presenting to the Medical Profession this 
volume, I wish it understood that my object is 
not for the purpose of adding to the list of authors, 
but from a conviction that some of the causes of 
our maladies have been overlooked, or have not 
received the attention which their importance 
demands ; and that several well known remedial 
agents have fallen into disuse, notwithstanding 
their value, and the rank they deserve in the cata- 
logue of remedies. The want of arrangement 
may also require an apology : but, as the work is 
composed of practical essays, complete in them- 
selves, and as I am without books of reference, I 
hope the authors whose opinions I have adopted, 
and the profession generally, will excuse the neglect 
of the courtesies usually bestowed, and the hurried 
manner with which the work is laid before them. 



Vlll PREFACE. 

My sole object being the promulgation of the 
views I entertain upon matters relating to Medical 
Science, and having confined my mind to the sub- 
stance, rather than the form — to the truth, rather 
than to the style of diction with which the essays 
are clothed, I hope the proper allowance will be 
made for any asperity of language, or peculiarity 
of stvle. 

In pursuance of this object, I would therefore 
say, that I do not pretend to be wiser than others 
who have had similar advantages; but having 
made nature my study, the opinions I entertain 
and advocate have been chiefly derived from the 
teachings of the animal economy by post-mortem 
examinations, and the effect of morbific and re- 
medial agents in clinical observations. Of the 
principles of the connection between the circulating 
and nervous systems, and the two tegumentary 
surfaces, I take a different view from the authors 
who have written on the subject; and where refer- 
ence is made to the effect of the morbific agent 
upon the capillary vessels or nerves, I do not pre- 
tend to say which of the two systems is first de- 
ranged, as the fact if correctly shown, would be of 
no practical importance. The shock or impression 
made upon either, would simultaneously influence 



PREFACE. IX 

the other, and where the capillary vessels and 
nerves are deranged, the secerning and secretory 
systems are incapacitated for the performance of 
their functions. 

The reasons for the adoption of instruments and 
bandages in my practice, were chiefly from the 
afflictions I suffered in the early part of my life, 
and a desire to become acquainted with the cause 
of the diseases, I was called upon to treat. Being 
also subject to hemorrhage of the lungs, with a 
weak or inefficient digestive apparatus, and a 
morbid sensibility to the effect of heat, cold and 
moisture, I consulted the authors who had writ- 
ten upon the subject, together with the most ex- 
perienced practitioners ; but finding all deficient 
in their therapeutical treatment, I changed my 
course and commenced a regular post-mortem 
examination of the cases that died from chronic 
diseases. This course, though somewhat tedious, 
enabled me to discover that the theory upon 
which I had commenced my practice was wrong, 
and that constipation was probably the cause of 
many afflictions ; that it derived its existence 
from a distension of the bowels, in some cases, 
and in others, from a gravitated condition, of the 
intestines with altered secretion of the liver. 



PREFACE. 



But while thus investigating the subject, I was 
called to a case of bilious colic, which, while it 
confirmed my position led to further research. 
The disease had resisted the remedies usually 
employed, and the patient being coyered with a 
cold clammy sweat, it was suggested that inver- 
sion of the body, or a suspension of it by the heels 
would give the desired relief. This was directed, 
and almost immediately the object was accom- 
plished. 

About that time the opinion of Dr. Abernethy 
on the importance of the digestive organs, and the 
salutary effects to be attained on the respiratory 
organs, by addressing our remedial agents through 
them, appeared so reasonable, (and as it was 
the prevailing doctrine,) I determined in my own 
case to give his views a trial. The cough and 
hemorrhage of the lungs required immediate 
attention, and by adhering to the principles, I 
was not long in discovering that the morbid sen- 
sibility had yielded, and by carefully observing 
the changes in the susceptibility to cold when the 
stomach and bowels were out of order, the fact 
presented itself, that cold, heat and moisture, could 
not affect any one as long as the vital laboratories 
were in harmonious action. Of this my own case 



PREFACE. XI 



and that of the colic presented the proof. Fre- 
quently when in health I was suddenly reduced 
by a flow of blood from the lungs, which estab- 
lished morbid sensibility, and kept me under its 
influence until the system had time to recruit. 
This result being different from the causes laid 
down by the various writers, and finding myself 
with my medical colleagues, unable to cure our 
patients, many of whom were dying from func- 
tional disease, as was manifest by post-mortem 
examinations ; I continued my investigations, and 
eventually came to the conclusion that if the pro- 
fession could be made familiar with the natural 
laws of life, and with the organs, their position 
and functions, it would lead to a better adaptation 
of our remedial agents, and a more certain relief 
to the afflicted. Being also satisfied that the 
causes assigned by authors, were not consistent 
when contrasted with the physiological laws of the 
economy, and tested by practice, I determined for 
the future to direct my attention to the objects 
that might enable me to discover why the com- 
mon elements which were created for the well- 
being of man, should be the most frequent cause 
of his painful maladies ; why, at one time we can 
withstand the action of the frigid zone, and at 



Xll PREFACE. 



another, through the ability of the vital functions, 
resist heat increased to a surprising degree ! as has 
been demonstrated by the experiments of the fire 
king. 

After making myself familiar with the external 
signs, and after ascertaining the seat of disease, as 
far as morbid appearance reveals such location, I 
cautiously approached my medical colleagues for 
their opinions upon minor points ; but without 
giving me any opinions of their own, at least two 
thirds of them referred me to the opinions of some 
favorite writer, and of course forced me back to 
my clinical observations and post-mortem exami- 
nations ; and I now submit them to the profession 
for further investigation, or criticism, as may be 
thought proper. But whatever may be the result, 
it cannot change the natural laws of the animal 
economy upon which these essays are based. Fine 
spun theories frequently mislead the weak, and 
obscure the pathway of the medical student ; but 
as it is through the mass of theories that truth has 
reached the light, these should not be discarded 
unless founded upon vague hypothesis. What we 
believe, we have found to be true, both in theory 
and practice, and our energies should be directed 
to new objects, calculated by reason and analogy 



PREFACE. Xlll 



to establish a complete system. The power of 
prejudice is however a barrier, and while aware 
of the difficulty of overcoming it, I have experi- 
enced the facility with which leading interests 
become alarmed at w 7 hat are thought to be inno- 
vations in theory and practice. But without 
dwelling upon the selfishness or caprice of man, it 
is my belief that no one should withhold or con- 
ceal a discovery that is calculated to mitigate the 
afflictions of his fellow men. The obscurity of 
our science and the fallibility of human reasoning, 
not only call for careful investigation, but a gene- 
rous dissemination of light and truth. But should 
our judgment be warped hy prejudice, or too 
much regard for dignity, and our mental energies 
encumbered by erroneous notions and doctrines, 
it is impossible we should advance, or exalt the 
character of our profession. Hence I believe that 
the professional importance of the practitioner is 
derived from a knowledge of the laws that govern 
the animal economy, and from the judicious em- 
ployment of remedial agents, in the cure of dis- 
ease. 

Books on the theory and practice of medicine, 
should treat each disease under a separate head, 
and the uncertainty of medical science should 



XIV PREFACE. 

excite the ambition of writers to the discovery of 
such medical truths as might keep pace with the 
progress of the age. Each author, if possible, 
should at least endeavor to rank with those of the 
preceding age, and it would be better for the pro- 
fession if each contributor would give only what 
he has, or believes he has discovered, without bor- 
rowing, curtailing or extracting opinions already 
published. For instance, what advantage w r ould 
the profession derive from a repetition in these 
essays of a description of the diseases which 
have their origin directly or indirectly from 
exhaustion or debility of the muscular system ? 
All such diseases are already treated with a full 
history of their symptoms and seat, and require 
only a correct description of their causes and 
effects. But such an abridgment would reduce 
volumes to the dimension of pages; would discard 
the discussions upon ancient and obsolete customs, 
and theories long since exploded, and confine 
authors to such points as would enable the prac- 
titioner to approach the sick-bed without confusion 
or embarrassment. 

With this view of the subject, it appears to me 
that the duty of both the physician and author, is 
to make himself thoroughly acquainted w 7 ith the 



PREFACE. XV 

anatomical structure — to examine the various tis- 
sues and organs, with their connections and rela- 
tive bearings in health, and the effects of one upon 
the other — to look into the mechanical functions 
— watch their symmetrical and alternate move- 
ments — the conformation of the body in the three 
principal cavities — minutely examine the vital 
functions — test every secretion in health and 
disease, and thereby detect the departures, and 
apply the remedies that accord with the patholo- 
gical condition. By such a course, it will be seen 
with what satisfaction to himself, and with what 
advantage to the afflicted, will the practitioner, 
thus qualified, be able to perform his duties. It 
will also be seen how necessary to his success, is a 
thorough knowledge of every science taught in 
our medical schools ; and, how important to the 
character of the profession, to the wants and 
condition of humanity, are the qualifications of 
the professor. On these is suspended the fate of 
millions ; hence no stubborn prejudice, no obsolete 
theories, or false hypotheses should be permitted 
to bias his instructions. He who teaches, should 
himself be learned ; not in poetic fancies of the 
science, but in sound doctrine ; in the laws of life, 
as found in the various constitutions of man. 



XVI PREFACE. 

Without the proper acquirements in the teacher, 
how can the profession he learned ? will the 
medical student he ahle from the crude or badly 
digested views of the preceptor to seek for, and 
discover the new features that are every day pre- 
senting themselves in practice? Or will he he 
ahle to discover the rudiments of a science that is 
ever progressive, and must continue to progress 
until the principles of life, in their organized and 
organic movements, are fully comprehended ? 



ANATOMICAL ARRANGEMENT 



CONFIGURATION OF THE BODY 



The abdomen is the largest cavity in the human 
body, and contains within its parietes numerous and 
important organs, by whose combined action materials 
are elaborated for the sustenance and growth of man, 
against the waste that is constantly going on from in- 
fancy to old age. And the derangement of these organs, 
whether functional, physical, or organic, contributes the 
greatest source of the diseases with which mankind 
are afflicted. Hence an accurate knowledge of their 
functions and conditions, both normal and abnormal, is 
indispensably necessary to the judicious and successful 
treatment of the many diseases and disorders which 
originate in this cavity. 

The form of the abdomen is oval, which often 
diners at different ages. It is bounded superiorly 
by the diaphragm, anteriorly and laterally, by the 
abdominal muscles ; inferiorly, by the true and false 
pelvis ; posteriorly, by the lumbar vertebrae, and crura 
of the diaphragm and psoas and quadratus lumborum 
muscles. Within this boundary is contained the peri- 



10 ANATOMICAL ARRANGEMENT 

tonseum, the organs of digestion, the t kidneys, renal 
capsules, and uterus ; also, the thoracic duct, the aorta, 
vena cava and the numerous branches of these vessels. 
The peritonaeum is a closed sac, and when opened 
presents one continued surface, which may be traced 
throughout the whole extent of the cavity of the 
abdomen and pelvis. It covers the viscera in such a 
manner, that they lie external, or posterior to it ; so 
that the viscera is covered by the peritonaeum, and 
yet they really lie behind it when it is opened. Like 
all serous membranes, it is smooth and polished. It 
contains within its shut cavity only a serous fluid, 
which serves to lubricate its opposing surfaces. This 
membrane being the principal agent in giving the 
several organs their ligaments, in its evolutions, 
forms the various processes known by the following 
names, viz : — The lesser omentum, the greater omen- 
tum, the splenic omentum, the colic omentum, the 
appendicular epiploicse, the transverse mesocolon, the 
right and left lumbar mesocolon, and the mesentery, 
which is the largest and most remarkable process 
of the peritonaeum. This portion is continuous with 
the descending layer of the mesocolon, that extends 
from the left side of the second lumbar vertebra down- 
wards to the right iliac fossa. This is what is 
known as the root of the mesentery. At this point 
the peritonaeum extends and enfolds the jejunum and 
ileum, from which it returns to the spine, forming a 
junction at the root ; and between the mesenteric fold- 
ings are arteries, veins, nerves, absorbents, and glands. 
This fixed root of the mesentery supports the convo- 
lutions of the small intestines, besides the numerous 
vessels attached. When these processes, with their 



AND CONFIGURATION. ' 1 1 

relative parts are in a healthy state, they are retained 
in their respective places by the co-operation of other 
dependencies ; and where these muscles become de- 
bilitated, the free portions of the peritonaeum are forced, 
by many causes, from their natural position. These 
displacements, with those of the organs of the ab- 
dominal viscera, I am fully convinced, from various 
dissections, are the source of a numerous class of dis- 
eases. The stomach, besides its connections with the 
diaphragm and sesophagus, is attached to the spleen, 
by the splenic omentum, to the liver by the lesser 
omentum, and to the arch of the colon, by the greater 
omentum. The duodenum, or first intestine, com- 
mencing at the left terminus of the stomach below the 
pyloric orifice, ascends obliquely and in a backward 
direction to the right side beneath the edge of the liver, 
where it touches the gall-bladder. At this point it 
makes a sudden turn, which is described as its su- 
perior angle. From this, it descends in front of the 
right kidney as low as the third lumbar vertebra, 
where the inferior angle is found. From this trans- 
verse portion, it passes obliquely upwards to the right 
side, and at the first lumbar vertebra it terminates in 
the jejunum. Thus, the duodenum makes three flex- 
ures, between the first and second of which, by a com- 
mon opening, it receives the bile and pancreatic fluid. 
It is here, also, that chylification is chiefly performed. 
The duodenum differs in several respects from the 
remaining portion of the small intestines, being fixed 
in its situation, and only partially covered by the peri- 
tonaeum, and in its caliber, is much larger near the in- 
ferior angle. The lower part of the duodenum is 
easily dilated, and the biliary and pancreatic ducts per- 



12 T ANATOMICAL ARRANGEMENT 

forate this division of the intestine obliquely opposite 
the inferior angle. This inferior portion crosses the 
aorta and the right renal vessels between the layers of 
the mesocolon, where the lower boundary may be seen. 
The superior mesenteric vessels pass in front of the 
termination and appear to compress it against the 
aorta, which retards the passage of its contents into 
the jejunum. The aliments which enter the duodenum, 
unless obstructed, must pass on slowly through it, 
favored by its position and the direction of its mus- 
cular fibres. Their passage is also accelerated by the 
action of the diaphragm upon the superior angle of 
the duodenum. In this intestine, there is but one 
point where a partial obstruction occurs, which is near 
its connection with the jejunum, where, if the aliment 
be retained too long, and become fermented, is the 
seat of those colics in which emetics act most favour- 
ably. 

The next division of the intestine is the jejunum, 
which terminates in the ileum. These are similar in 
their configuration and anatomy, except that the jeju- 
num is more vascular and feels thicker and larger 
than the ileum, which difference is apparent, when the 
commencement of the former is compared with the 
termination of the latter. These are divided only 
by an imaginary line, which makes the jejunum two 
thirds as long as the ilium. The jejunum, which is 
generally found empty, occupies the umbilical, the 
ileum the hypogastric and right iliac regions, where 
it terminates in the csecum, which it appears to per- 
forate, forming the ileo-csecal valve, which being 
horizontal is so constructed as to prevent regurgita- 
tion from the colon. 



AND CONFIGURATION. 13 

These intestines being concave posteriorly, are 
attached at the root of the mesentery, while anteri- 
orly their convolutions describing an oblong circle are 
left free to gravitate into the pelvis when unsupported 
by the abdominal muscles. 

The anatomical arrangement of the intestines is 
such, when in their proper position, that their ver- 
micular motion is aided by the abdominal muscles 
and diaphragm in propelling their contents through the 
ileo-caecal valve and onwards. These intestines, then, 
being subject to fall into the pelvis, are the seat of 
those violent colics, so difficult to cure by the ordi- 
nary treatment. Many other diseases arise from 
the same cause, including dyspepsia, which are also 
difficult to cure by medicines alone. But by mechani- 
cal agents much may be done for the relief and cure 
of the large class of diseases which originate from 
visceral displacements, and a successful and extensive 
use of these agents for the last twenty-one years, 
confirms the theory already established by anatomical 
facts. The large intestine forms about one-fifth of the 
intestinal canal, and is subdivided into the caecum, 
ascending colon, transverse colon, descending colon, 
sigmoid flexure of the colon, and rectum. From the 
caecum to the termination of the colon, there is no 
marked distinction between the different divisions. 
The caxum is situated in the right iliac fossa, in 
which region it is fixed by the peritonaeum and cellular 
membrane. From the caecum, the colon ascends 
to the inferior surface of the right lobe of the liver, 
at which it is attached. It thence forms a transverse 
arch acros to the other, side, anterior to the small in- 
testines, being attached to the stomach through the 

2* 



14 ANATOMICAL ARRANGEMENT 

greater omentum in the middle, and at its left angle to 
the spleen. This arch of the colon crosses the inferior 
boundary of the epigastrium, and upper part of the 
umbilical region, and making an obtuse angle in the 
left hypochondrium, it becomes the descending colon, 
which being attached to the left kidney and psoas 
muscle, by the peritonaeum and cellular membrane, 
extends to the left iliac region, forming the sigmoid 
flexure, which is connected but slightly and loosely in 
the iliac fossa. 

The rectum commences at the left sacro-iliac junc- 
tion, and extends from the sigmoid flexure of the colon 
to the anus. The direction of the rectum is oblique 
towards the middle line, as far as the lower end of the 
sacrum, where it curves and makes a forward direction 
to the perinEeum, and turning down ends at the anus. 
The rectum is connected with the sacrum, coccy- 
gis, meso- rectum, bladder, vesiculse seminales, prostate 
gland, and, in the female, to the uterus and vagina. — 
The inferior third of the rectum is devoid of attachment 
to the peritonaeum, and at this portion it is generally 
found much dilated above the insertion of the levator 
ani muscle. 

Having now traced the colon from the commence- 
ment to its termination, it is obvious that the contents 
are propelled onward by a different force from the one 
that propels them through the small intestines. When 
the anatomist reviews the muscular fibres, one set being 
circular, and another longitudinal, and when one part 
of the same bowel is ascending, while another is trans- 
verse, and a third descending, it presents a fair infer- 
ence that the excrementitious materials are made to 
pass slowly through the ascending and transverse 



AND CONFIGURATION. 



15 



portions, by the action of the longitudinal and circular 
fibres. By means of these fibres, the colon is con- 
stricted in part, and formed into saccated valves, 
which prevent, in the ascending colon, the weight 
of the excrement from overcoming the force below. 

In the right half of the transverse colon, the saccated 
valves act as a check to the excrement, in passing this 
inclined part, and in the left half as a support in the 
upward movement. The contents in the descending 
colon, are also retarded in the downward tendency, by 
the saccated valves, otherwise their specific gravity 
would force them on with too much rapidity. The sig- 
moid flexure is also a checking point, or reservoir, which 
being assisted by the levator ani muscle, prevents the 
faeces from being constantly in contact with the sphinc- 
ter muscles and- nerves. Were it not for this wise 
arrangement there would be a continued disposition of 
the parts to discharge their contents. The large in- 
testine, in its several divisions, is liable to obstructions, 
which invariably give rise to disease. The csecum is 
liable to enlargement from the retention of its con- 
tents, which eventually establishes a chronic disease 
of the mucous membrane. The cause of this retention, 
is referable to the ascending colon — in the loss of tone 
in the tissues of which it is composed, a relaxed con- 
dition of the muscular parietes of the 'abdomen, and 
also in a debility of the propelling force of the small 
intestines. 

The transverse colon is also subject to accumula- 
tions within its most pendulous portion, which give 
rise to the symptoms complained of by dyspeptics, — 
such as pain, first in the right, and then in the left 
hypochondrium, the sensation of dragging downward, 



16 ANATOMICAL ARRANGEMENT 

and of fulness and heat in the umbilical region. 
All of which symptoms I have speedily removed by 
giving support to the ascending and transverse colon, 
with mild aperients, and sometimes alteratives, t 

The descending colon is also obstructed by the dis- 
placement of the sigmoid flexure. This important re- 
servoir, is as stated, in the left iliac fossa, and of 
course at the marginal brim of the pelvic cavity. But 
when overloaded, it is carried down into the pelvis 
where it was never designed it should be ; and where, 
by long neglect its attachments become debilitated and 
lengthened. After which, unless assisted, it remains 
within that cavity very much to the prejudice and dis- 
comfort of the patient. Thus situated, it is the cause 
of haemorrhoids, and a sensation, after an evacuation, 
of fulness, until a movement of the intestines, or 
change of position replaces the flexure. This sigmoid 
flexure of the colon has been, and in my opinion, may 
be considered one of the principal causes of prolapsus 
uteri. In nine out of ten cases examined, the os tincae 
was found inclined to the ricrht, whilst the fundus was 
on the left side, and when we take into consideration 
the positions of the lateral ligaments of the uterus, 
with the sigmoid flexure resting upon it, it is but what 
we should expect from the anatomical arrangement of 
the parts when displaced. I therefore invite my medi- 
cal brethren to examine the position of the os uteri, 
and rigidly test the facts. If they find them wrong, it 
will be but proper to proclaim it, and continue the 
practice that has hitherto tortured the female portion 
of our race ; but if my position should be confirmed, 
let those unsafe and indelicate remedies, founded on 
false hypothesis, be discarded forever from their prac- 



AND CONFIGURATION. 17 

tice, and the remedies that are based on anatomical 
facts be introduced in their stead. 

Having thus briefly noticed the alimentary canal, in 
connection with the functions that regulate the move- 
ment of its contents, I proceed to the examination of 
the means by which these organs are retained in their 
appropriate places. But as the parietes of the abdomen 
are made up from muscles and fascial membranes, all of 
which are fully described in their origin, insertion, 
and arrangement of their fibres, it will suffice my pur- 
pose to enumerate the muscles, and give what experi- 
ence has taught me in reference to their joint offices. 
The muscles that assist in sustaining the viscera of the 
abdomen, are the two external and two internal oblique, 
the two transversales, the rectus abdominis, the two py- 
ramidales, the four serrati, the fibres making the inter- 
costales, the two latissimus dorsi, in their connections 
with the muscles of the abdomen and diaphragm. A 
knowledge of the origin and insertion of these, with the 
mechanical functions as indicated by the direction of 
their fibres, is exceedingly important. The mechani- 
cal movement of the parts is what may be termed 
flexion and extension ; the action produced by inspi- 
ration on the lower two thirds of the abdomen, is one 
of extension, which dilates it, and forces the parietes 
outward and downwards. Flexion occurs in expira- 
tion, where the upper third contracts, diminishing the 
abdomen, and compressing the viscera to their proper 
form and relative position. This movement depends 
in part upon a natural and involuntary elasticity and 
contractility of the mucles. These are also influenced 
to some extent, by habit and volition. So that by the 
natural action of their fibres, all the organs are re- 



18 ANATOMICAL ARRANGEMENT 

tained in their places, where they can perform their 
specific functions. Without this bandage-like protec- 
tion and pressure of the muscles upon the viscera, 
very few of their functions could be carried on, nor 
would the equilibrium in the muscular system be pre- 
served. 

In the history of the diseases, with their pathologi- 
cal condition, it will be seen that some of the most 
desolating epidemics with which the human family 
have been afflicted, have had their origin within the 
cavity of the abdomen, and when we look at the 
number of organs it contains, their complicated struc- 
ture, and at the importance of each group to the pre- 
servation of our health, we may ask, why they have 
escaped the critical attention of medical authors? In 
the development of the organs of the chest, nothing is 
left for conjecture ; and is it not strange that so much 
attention and laborious research should have been ex- 
pended upon the cause of diseases originating in the 
abdominal cavity, without even a reference to the 
gravitation of the viscera of the abdomen and its 
fluids? It is an established maxim, I believe, in the 
science of medicine, that a cause acting either chemi- 
cally or mechanically, must in its action, have suffi- 
cient force to change the natural law of the parts, or 
the constituents of the fluids, before a morbid change 
is established. Hence the necessity of critically ex- 
amining the effects of visceral displacement. 

The organs within the cavity of the abdomen are 
not only more frequently the seat of disease than those 
located in the other cavities of the body, but in point 
of danger, are at least equal to those of the chest and 
brain. The delicacy of the capillary vessels, and the 



AND CONFIGURATION. 19 

numerous terminating extremities of the nerves, which 
are found in and upon the internal tunic of the intes- 
tines, render the latter highly susceptible to morbid 
action. From the relations of this part of the animal 
organization, and the incessant motion of the intes- 
tines, should we not look both for frequency and 
severity of disease, even if there were no possibility 
of displacement ? During a practice of thirty years, 
my mind has been impressed with the fact, that two- 
thirds of our maladies may be traced to the unnatural 
action of the organs and tissues, produced by displace- 
ment. In no other cavity is there to be found primary 
inflammation so frequent, nor so many diseases from 
accidental disturbance. Even tubercles, which derive 
their origin from a hereditary latent diathesis, are called 
into action by the irritation of the intestinal canal, and 
root of the mesentery, and found upon examination of 
their morbid product, to be more numerous in the ab- 
dominal viscera, than in any other part of the sys- 
tem. In fevers of almost every grade, the bowels are 
distinctly marked by inflammation, or engorgements, 
and their mucous membranes, by increased thickness, 
or ulceration. 

But in the examination of the abdomen and the 
organs therein contained, it is necessary we should 
make ourselves familiar with its external configuration, 
which, as before said, is of an oval form, and if we 
draw a transverse line, passing through the centre of 
the umbilicus, it will represent the base of the two half 
cones with their apices opposite, one at the pubis, and 
the other at the ensiform cartilage. By this division, 
and a familiarity with the organs, and the regions in 
which they are found, there will be no difficulty in de- 



20 ANATOMICAL ARRANGEMENT 

tecting the several misplacements of the viscera. The 
walls of the abdomen allow us by the touch to deter- 
mine the position, size, and degree of sensibility; 
and whether there be any extraneous bodies contained 
within them. In the most healthy individuals, where 
bodily exertion has been used during the day, it will be 
found that the lower half cone of the abdomen is much 
increased in the hypogastric and inguinal regions, and 
a corresponding depression in the epigastric, with an 
increased fulness in the upper margin of the lumbar 
regions ; but in the morning after resting in the re- 
cumbent posture, each portion will be restored to its 
natural position, unless the attachments have become 
so much distended as to impair the natural contrac- 
tility of the muscles. The peritonaeum to which all the 
organs of the abdomen are attached, being one of the 
smoothest surfaces, when lubricated with a healthy 
secretion, moves upwards and downwards upon itself, 
without our knowledge, and of course is dependent 
upon muscular power for the ability to perform 
its office. In my clinical pursuits I have observed 
many cases of fever produced by the displaced con- 
dition of the small intestines and transverse colon ; 
and it may be regarded as a rule, that where the small 
intestines are forced below their primitive boundary, 
the transverse colon necessarily sinks to a greater or 
less extent; and where it is much displaced, it pro- 
duces a contraction about two inches above the um- 
bilicus. If the muscles are relaxed, or in cases of 
children of strumous habit, the patient becomes dis- 
figured by the change of the viscera, and the walls of 
the abdomen, in the upper half, become distorted and 
contracted towards the spine. The lower half also, 



AND CONFIGURATION. 21 

loses its regularity ; and, like a sack filled at the lower 
end, with the upper portion fixed to the sternum and 
cartilaginous portion of the ribs, instead of the sym- 
metrical oval figure, that gives to the human form its 
robust and harmonious appearance, it hangs like a 
pendulous inorganic substance, with the hypogastric 
and inguinal regions distended. 

The mobility of the intestines, therefore, with th e 
elasticity of the muscular movement, and the known 
axis of the body in relation to the true pelvis, should 
have taught the anatomist, that so soon as the loss 
of power takes place in the parietes of the abdo- 
men, and the axis of the body is changed, the bowels 
in the lower boundary would be permitted to gravitate 
to the true pelvic cavity, and those in the upper, to 
the false cavity, producing unnatural deformity, and 
sapping as it were, the foundations of life. The me- 
chanical functions of the walls of the abdomen, require 
that every tissue should be possessed of elasticity and 
contractility sufficient to allow the viscera, which the 
parietes protect and support, to increase their bulk 
without disturbing these functions, and in like manner, 
in a sudden reduction of the size of the viscera by the 
laws of contractility, the parietes are enabled to main- 
tain the organs in harmonious contact, and preserve 
their symmetry of form. 

But let the reader observe the haggard and emaci- 
ated appearance of a large number of those he meets, 
and let him inquire whether the predisposing cause is 
not the result of a morbid action upon the mucous 
membranes contained within the abdomen, which gives 
rise to a rapid absorption of the adipose matter, and 
cellular tissues, as is produced in tubercular consump- 



22 ' ANATOMICAL ARRANGEMENT 

tion. Then let him examine our position, and care- 
fully look and contemplate the effects of a relaxation 
of the muscular walls of the abdomen — of the descent 
of the small intestines, sigmoid flexure, transverse 
colon, and omental processes, upon the inferior organs 
and tissues within the cavity — let him look upon the 
effect produced upon the stomach, the liver, the spleen, 
and upon the entire chylopoietic organs, under the in- 
fluence of the gravitated solids and fluids — the motion 
and the changes that are necessary for the muscles of 
the abdomen to undergo, as a vital apparatus in sus- 
taining the weight of the viscera — in resisting the ac- 
tion of the diaphragm ; and let him examine the 
mechanical functions of the muscles destined to sup- 
port and compress the organs, and then ask, what 
is the object and purpose of the arrangement, if it be 
not for the well-being of the economy? Let him 
further inquire why one set of fibres are so arranged 
as to act as extensors, while another performs the 
office of flexion ? — and if it be not by the aid of the 
muscles and the peritonaeum, that these organs are re- 
tained in situ, supported by relative dependencies and 
their reciprocal movements, and the harmony of the 
organism maintained, and its symmetry preserved ? 

Then if w r e take a comprehensive view of the or- 
gans of the abdomen, with a history of the diseases 
arising from a disturbance of the digestive apparatus, 
and look at the influence of the mucous membrane, the 
capillary vessels and nerves, upon the skin, we may 
readily see the necessity of their healthy action. The 
emunctories of the skin which separate the limpid fluid 
from the blood, and carry it off by insensible perspira- 
tion, perform an important office, which, if deranged, 



AND CONFIGURATION. 23 

influences the whole system. This function is often 
suspended by derangement of the viscera. 

This is manifest in cutaneous diseases, which de- 
pend upon the state of the internal organs. The dis- 
turbance of the intestinal mucous membranes with the 
capillary vessels and nerves, is capable of deranging the 
healthy functions of the parts, though they are acting but 
in moderate force. In like manner, a change in one or 
more of the internal organs, not unfrequently estab- 
lishes morbid action in remote parts of the system. 
Is it not then probable, that by allowing the viscera of 
the abdomen to gravitate from their proper position, 
the diseases which hitherto have been attributed to 
heat, cold, moisture, &c, may derive their origin from 
such displacement ? In my practice I have been en- 
abled to trace the origin of simple, continued bilious 
and inflammatory fevers to over exertion — too long 
standing in an erect attitude — as clerks at their desks, 
printers at their cases, shopkeepers at their counters, 
&c, which produce debility of the muscles, and con- 
sequently a gravitating tendency of the abdominal 
viscera and fluids. 

What anatomist therefore, or physiologist, would 
venture to doubt the deranging influence of the ab- 
dominal viscera, notwithstanding there is a wise pro- 
vision in nature, adapting the habit of the deranged parts 
to keep up a partial harmony ? But when we make 
all allowance for this ability of nature, to alter the 
sensibility of the part, so that its derangement may 
not be noticed by the individual afflicted, can it be 
supposed that the functions of these altered organs, 
are what they should be ? When w T e take into con- 
sideration the number of organs, and the several tis- 



24 ANATOMICAL ARRANGEMENT 

sues surrounding or forming a component part, all of 
which are endowed with peculiar sensibility, and pos- 
sessed of the powers of vitality, in proportion to the 
constituent elements of which they are formed ; and 
when we consider that the least alteration of any one 
will derange the others, and gradually spread over the 
whole animal economy a morbid influence, we may 
readily conceive that vital laboratories are contained 
in this cavity. Yet the author of "Females and 
their Diseases," says and believes, " that the endan- 
gium, membrane of the vessels, is the manufacturer 
of blood;" and without testing his theory upon 
himself, or without considering that the entire or- 
ganism of man receives its support from the blood 
after it is elaborated by the chylopoietic and respira- 
tory organs, he expends his illustrations upon Helen 
Blanque, who believes him, and dies of the dry wilt, 
for the purpose of establishing his theory. But 
as it is impossible to be serious in the contemplation 
of such romance, I regret the necessity that forces 
upon me the extraordinary fancies of the Professor, 
and instead of adopting his illustrations, it has been 
an object with me to seek the true source of dis- 
eases to which the human family are liable, and 
apply the appropriate remedies. In my researches, 
I have been astonished at the number of diseases 
originating from displaced organs, and I think those 
who are willing to observe, and be governed by the 
pathology and symptoms radiating from this source, 
will be alike surprised at the catalogue. In children 
it is well known that worms produce convulsions, and 
it is also known what is the effect upon the entire sys- 
tem of a protruded portion of the intestines through 



AND CONFIGURATION. 25 

the natural or preternatural opening. If a man who 
labours under hernia be asked what change it pro- 
duces upon his sensibilities, when a portion of his 
bowels protrude, he will at once answer, " it saps as it 
w T ere my entire strength, and if not returned I am in- 
capacitated for business of any kind." And who 
among practical physicians has not observed the effect 
of strangulated hernia, — the violent order of the symp- 
toms — their tendency to a speedy dissolution if not re- 
duced, or if the stricture be not removed by the scalpel ? 
Any dragging down, therefore, of the viscera of the 
abdomen, has a tendency to change the parts from a 
natural to a preternatural state — results which are 
manifest in various ways. 

Having thus noticed the anatomical arrangement 
of most of the organs contained in the cavity of the 
abdomen, with their attachments and prominent con- 
nection, I now proceed to examine the external ap- 
pearances, in health and in disease, as observed in my 
clinical pursuits. The external boundary of the abdomen 
w T e find, is over two thirds composed of muscles, fibres 
and membranes, with their several integuments ; and 
if we examine the abdominal and respiratory muscles 
— their origin and insertion, as described by the ana- 
tomical writers, it will be seen they not only concur 
in the offices, but have assigned the mechanical func- 
tions, to sustain the viscera of the abdomen in their 
proper place, and thereby assist in the function of 
respiration. From the alternate action in inspiration 
and expiration, it will also be seen that in the former, 
the abdominal muscles are forced downwards and out- 
wards, extending the capacity of the abdomen and 
chest, while in the movement of the latter, the upper 



26 ANATOMICAL ARRANGEMENT 

portion of the muscles act as flexors, and contract the 
cavity — compress the viscera obliquely upwards and 
backwards, and thereby force the diaphragm upward, 
— narrow the chest — compress the lungs, and by 
these involuntary movements, constitute expiration. 
In these mechanical functions, besides the compres- 
sion of the viscera of the abdomen and chest, every 
organ is kept in its place, that the so called cavity may 
be one combined whole, or vacuum plenum, suscepti- 
ble of distension and contraction by the symmetrical 
movements of the parietes. Thus, the organs are kept 
within their ellipsis, and from the anatomical arrange- 
ment of the diaphragm and spinal column, with its junc- 
tion at the sacrum and pelvic bones, there must be an 
antagonizing point at the linea-ilio pectineal line. By 
the downward movement of the diaphragm, the force 
is thrown upon the upper marginal brim of the pubic 
bones, and at the line of the insertion of the oblique 
muscles, and their tendons, with the origin of the recti 
abdominal muscle. This fact is established by the axis 
of the body when in an erect position. The inclination 
from the promontory of the sacrum to the symphysis 
pubis is equal to an inclined plane of sixty degrees in 
the male, and fifty-five in the female. This inclination 
of the pelvic cavity at the marginal brim enables the 
abdominal muscles to sustain the weight of the viscera, 
and antagonize the force of the diaphragm. By this 
arrangement the viscera derive their principal support, 
and by which the organs are enabled to perform their 
several functions. Hence, the external configuration 
is owing to the size and location of the viscera, and 
the viscera are dependent upon the strength, elasticity, 
and contractility of the parietes, for their symmetrical 



AND CONFIGURATION. 27 

support. The arrangement of the peritonaeum, in 
giving a coat to the organs, and fixing the attachments 
of the viscera, by the duplicatory ligaments, leaves the 
viscera free in many parts to allow the organs the free- 
dom required in their mechanical or organic functions. 
Consequently the parietes adapt themselves, through 
their vital elasticity and contractility, to the size and 
position of the organs, and when in a healthy condition, 
we find the natural oval form of the trunk maintained 
and observed in the perfection of the human figure. 

From a knowledge of the laws which govern the 
organs, and enable them to perform their specific func- 
tions, is it not strange that the various writers should 
have overlooked the cavity of the abdomen with its 
important assemblage of organs? all of which are de- 
pendent upon the voluntary or involuntary movements 
of the nine muscles, and the connection with the serratus 
and latissimus dorsi. Sir Charles Bell, in his researches 
on the nervous system, which presides over the respi- 
ratory muscles, conclusively assigns the functions, and 
why is it that the physiologist has not been called to 
the mechanical functions of this part of myology ? The 
failure of these muscles invariably leads to the destruc- 
tion of health, and eventuates more frequently in 
death, than from all other causes — yet it is not to 
be understood that the failure is the remote cause in 
all, but it becomes an exciting one in some, and an 
irritating contributor to every functional or constitu- 
tional disease. In the debilitated or exhausted power 
of those muscles, it has been already shown, the 
viscera and fluids gravitate, and by the mechanical 
functions, with the assistance of the intercostal 
muscles, diaphragm and mobility of the ribs, inspira- 



28 ANATOMICAL ARRANGEMENT 

tion and expiration are performed. Hence is it not evi- 
dent and demonstrable that the lungs in their hinder 
and lower portions fail to dilate, and be traversed by 
the air ? On such failures, which leave the blood in a 
pathological condition, is it not clear that the lower 
portion of the lungs becomes the seat of fatal conges- 
tions ? Hence the importance of mechanical agents 
to assist the organs in this debilitated condition, until 
their lost energy is restored. 

The failure of the organs of the abdomen is easily 
detected by a careful examination of the physiognomy 
of the patient. The strength of the body and the state 
of the mind, with the color and the condition of the 
skin, are indexes of prevailing malady. But having 
thus ascertained the condition as far as sight enables 
us to determine it, we next make a careful explora- 
tion of the chest, by percussion and auscultation. After 
which sight and touch is combined, and having deter- 
mined by the first the configuration, we trace by the 
second the organs that are liable to displacement, and 
ascertain, if possible, their size and position. Such 
examination is absolutely necessary incases where the 
predisposing or exciting cause is suspected to have 
originated in the gravitation of the solids and fluids ; 
without such examination our prognosis must more 
frequently destroy the confidence of the patient than 
otherwise. The importance of the organs of those two 
cavities, demands the closest investigation, and if we 
expect to sustain the dignity of our profession, we must 
do it by mitigating or curing the afflictions of the hu- 
man family. The want of such attention is already 
manifest in the lost confidence of the public, and in 
the rapid growth of new systems which may be as- 



AND CONFIGURATION. 29 

cribed to the inattention of the faculty, and the credu- 
lity of the public. But if we discover that the difficulty 
arises from hereditary taint, and the appearances are 
not of a character to define the cause, the habits of 
the patient, the age, sex, constitution, idiosyncrasy if 
any, and occupation, will enable us to judge correctly, 
and apply the agents adapted to the condition of the 
patient. 



CHRONIC DISEASES 



VISCERA OF THE ABDOMEN 



As the history of subacute diseases has attracted 
the attention of the medical profession in all ages, 
owing, perhaps, to their insidiousness, their harass- 
ing tendency and fatality; and as the real cause 
of many of them, has hitherto been overlooked, or 
unnoticed by the medical authors who have written on 
the subject, I propose to show, in the following essay, 
what it is, the means for its prevention, and the indi- 
cations of treatment, of the various diseases arising 
therefrom. In doing this, my object is simply to give 
an exhibit of the truth of my practice and experience. 

For illustration, I have grouped together the follow- 
ing diseases, for a summary consideration, viz. :• — 
constipation, dyspepsia, chronic diarrhoea, gastritis, 
enteritis, peritonitis, gastro-enteritis, hepatitis, spleni- 
tis, and bilious colic, and predicate the opinion, that 
the most frequent source of all those diseases, is mis- 
placement, or subsidence of the abdominal viscera. 

1. Constipation, — By this term, we are to under- 
stand a condition of the bowels that moves less fre- 



CHRONIC DISEASES, ETC. 



31 



quently than is natural in a healthy state. In some 
the discharge is once or twice in twenty-four hours, 
whilst in others, owing to habit or peculiarity of con- 
stitution, it varies from two to ten days. The causes 
of this, derangement, as found in our medical records, 
are numerous, and in some instances correct; but 
every medical practitioner will find a misapprehension, 
either in the cause assigned, or in the efTect of the 
remedial agent prescribed, from its failure to fulfil the 
indications. From such disappointments, and observ- 
ing the effects upon the general economy, as well as 
from the history obtained from numerous patients 
laboring under one or another of the chronic diseases 
above enumerated, I have thrown together the remarks 
that follow. 

In the second year of my professional career, I was 
called to attend a case of bilious colic, and after ex- 
hausting the remedies that were usually applied, the 
possibility of relief was suggested by reversing the 
erect position, or suspending for a few minutes the 
patient by the feet. A successful trial in a similar 
case had been witnessed, and as the usual remedies in 
this had failed, I directed the experiment to be made. 
The patient at the time was covered with a cold 
clammy sweat, and on the change of position, and 
immediately after the concussion given by the opera- 
tors, a quantity of gas escaped — a free alvine discharge 
was made from the bowels, and in twenty minutes the 
patient was entirely relieved from the symptoms of 
colic. 

At the time I was myself a sufferer, with occasional 
hemorrhage of the lungs and symptoms of hemor- 
rhoidal tumors, with a sensation of fulness in the 



32 CHRONIC DISEASES OF THE 

lower part of the abdomen and pelvis. But after ob- 
serving the relief obtained from inverting the body of 
the patient, and after a successful experiment in my 
own case, it occurred that a bandage would secure the 
relief so anxiously sought. A handkerchief w^s ac- 
cordingly applied, from which much advantage was 
derived, although time was required to improve the 
habit of the secretions, and the other consequences of 
constipation. 

From this, and the subsequent experiments made 
upon myself, I extended my observations to all the 
cases that came under my care, and soon discovered 
that the exterior walls of the abdomen, in the greater 
number of cases, had a depressed and pendulous ap- 
pearance, with contraction in the upper half of the 
abdomen. This appearance, taken in connection with 
the symptoms in dyspepsia — with the relief obtained 
from the inversion of the body — and the application 
of suitable bandages, suspensory jackets, and sup- 
porters of various forms, led me to the conclusion that 
displacement of the bowels was the principal cause 
of the disease. But uncertainty as to the particular 
portion that seemed to be thus displaced, and my suc- 
cess urging to further inquiry, I examined every case 
within my reach, whether treated by myself or others, 
whose death had been caused either by chronic or 
acute disease; and now, after thirty years practice, I 
am satisfied that the most frequent source of consti- 
pation arises, first, from the displaced condition of the 
sigmoid flexure of the colon, and over distension of 
the intestines. 

Secondly, from a depression of the small intestines 
and transverse colon, they being permitted to gravi- 



VISCERA OF THE ABDOMEN. 33 

tate lower than is consistent with their natural func- 
tions, thereby producing a mechanical obstruction in 
the caliber of the intestines and blood-vessels. And 
lastly, from a derangement in the circulation, for the 
fluids of the abdominal vessels gravitate as well as the 
solids — especially since venous blood is not propelled 
by what is termed the vis a tergo alone, but by the 
pressure made upon the veins by the action of the 
neighboring muscles, and atmospheric pressure, and 
by the elasticity and contractility of the capillaries and 
venous radicals. These forces are diminished whenever 
the muscles lose their power to retain the viscera in 
their proper places, and derangement in the secre- 
tions follows. Hence it is obvious that constipation 
would be a legitimate result. 

Again, by the gravitated intestines we not only 
have mechanical obstructions to contend with in their 
caliber, but obstructions to the course of the blood, 
and congestions of various kinds, as any impediment 
in a large blood-vessel emanating from capillary ves- 
sels, must produce obstructions in those vessels, and 
of course congestion in the parts from which they 
proceed. For instance, if the capillaries of the liver, 
from chronic disease, or any other cause, cease to 
transmit the blood through that organ within the 
usual time, the vena portarum becomes distended and 
congestion necessarily takes place in the stomach, 
bowels and all the parts from which the veins empty 
themselves into the vena portarum. 

The primary sources then, of all the diseases enu- 
merated above and arranged in the order of their im- 
portance, are as follows : 

4 



34 CHRONIC DISEASES OF THE 

I. The descent of the sigmoid flexure, producing 

mechanical obstruction. 

II. The descent of the convoluted portions of the 
small intestines. 

III. The descent of the transverse colon, which 
produces obstruction at its angles. 

IV. Over distension of the intestines, whereby their 
capacity to adapt themselves to their contents, 
is lost. 

V. Functional derangement of the liver, with dimi- 
nution of the secretions, which stimulate the in- 
testines ; and this is often a consequence of the 
former condition. 

These diseases give rise to an impacted or distended 
colon — diminished contractility of the muscular coat 
— enfeebled susceptibility of the colon, and other por- 
tions of the bowels. From these results combined, 
habitual constipation is perpetuated in its ravages 
upon the entire economy, and if not the first, are the 
principal causes of the disease. 

The disease, called dyspepsia, has unfortunately 
been more frequently maltreated, perhaps, than any 
one of the chronic diseases seated within the range of 
the digestive apparatus. There are various morbid 
states of the stomach, such as irritation, chronic gas- 
tritis, vascular engorgement, nervous affections, and 
gastric debility ; all of which produce confusion, and 
lead to serious errors in practice. The treatment, as 
laid down by most of our old writers, is only applica- 
ble to a certain condition, without a reference to 
others of a different character. This unfortunately 
misleads the unobserving class of the profession, whose 



VISCERA OF THE ABDOMEN. 35 

treatment is confined to the name, rather than the 
pathology of the disease. 

There are, however, many who doubt the existence 
of a distinct gastric disorder, whilst Broussais and his 
disciples refer all affections, usually called dyspepsia, 
to gastric irritation, or inflammation ; but these opin- 
ions have not been generally adopted. Dyspepsia is 
frequently the consequence of depression of the natu- 
ral action of the stomach, from a diminution of the 
nervous and muscular power, which constitutes the 
basis, and in the advanced stages of the disease, there 
may be superadded acute or sub-acute inflammation 
of the mucous membranes of the stomach and bow T els. 
But these are mere consequences which may be re- 
moved by appropriate remedies, while the original dis- 
ease is often left uncured. As dyspepsia most gene- 
rally occurs under a complicated form, it requires 
accurate observation to distinguish true dyspepsia 
from constipation, chronic enteritis, chronic hepatitis, 
or splenitis, or is the result of these diseases. The 
morbid vascular and nervous action liable to arise 
from the gravitation of the bowels and fluids should 
not surprise any one, when the intimate connections of 
the nervous and vascular systems are observed, which 
are concerned both in location and functions. 

Of thirty-three examinations which I made of persons 
who died of some one of the diseases above named, 
twenty-eight had a portion of the bowels in the pelvis, or 
had labored under chronic inflammation of the stomach 
and bowels. Twenty-one lived what is called a seden- 
tary life. The remainder were common laborers. No 
one, however, could be traced to strumous habit. The 
description of three of these cases will illustrate the 



36 CHRONIC DISEASES OF THE 

whole, but in each of these three, there was a difference 
in the organs diseased, and a great variety in the shades 
of morbid action. Some had a thickening of the mucous 
membrane without ulcers ; others, with softenings and 
stripes or spots. In these examinations, the redness 
or injected appearance of the mucous membrane in the 
dependent parts was owing, in my opinion, entirely 
to displacement, and the tendency of the fluids to gra- 
vitate, and not, as is generally believed, the result of 
articulo mortis, which is but a consequence, not a 
cause. 

The capillaries, in ordinary health, are endowed 
with a peculiar degree of sensibility* which enables 
them to resist the entrance of such fluids, as are not 
designed to aid in the performance of their natural 
functions ; for so long as these vessels retain their 
natural tone, the red blood cannot enter them. Hence 
those injected appearances are owing to debility, and 
the tendency of the fluids to gravitate. A post-mortem 
examination which I made in a case of chronic gas- 
tritis illustrates this position. The organic changes 
in the stomach were as follows : A portion of the 
mucous coat was thickened ; whilst at the left ex- 
tremity it had an elevated appearance in spots, and 
was evidently softer than it should be, as it and the 
spots were easily removed by the back of the scalpel. 
Between these spots, were stripes of thickened mem- 
brane, which appeared condensed, and difficult to be 
removed. In the right extremity were various forms 
of ulcers ; but none more than a quarter of an inch in 
diameter. Some were found in the pyloric orifice, the 
surrounding membrane of these parts being apparently 
healthy. The liver was in a normal state, with the 



VISCERA OF THE ABDOMEN. 37 

exception of engorgement of the capillaries. The 
transverse colon of the arch was resting at the root 
of the meso-colon, the right and left angles evidently 
thickened and contracted, with marks of softening of 
its inner membrane. The small intestines were found 
in the true pelvic cavity, with several enlarged tortuous 
blood-vessels, which could be traced to a twist in the 
bowel, where the vessel w T as obstructed. All that por- 
tion of the intestines in the pelvis, was engorged with 
blood, resulting from obstructed blood-vessels. The 
mesenteric glands were evidently enlarged, and seve- 
ral of them softened in their centre. This case had 
been treated ten years for dyspepsia. 

In the second case the patient was aged thirty- 
three — had been six years afflicted, during which time 
he made a sea voyage— had been treated in the com- 
mencement for bilious fever, from which he recovered, 
leaving constipation of an obstinate character. This 
disease continued ten months, after which it alternated 
with diarrhoea, in consequence of which change, the 
sea voyage had been prescribed. But instead of 
benefit, his sufferings were increased. His stomach 
became affected with the usual symptoms of indiges- 
tion, and he was treated by his physician for dyspep- 
sia, originating from disease of the liver. After 
having continued the use of medicine for eighteen 
months, he resorted to the springs as a last alterna- 
tive, at which place I became acquainted with him, 
and being an invalid myself, we spent our time to- 
gether, and during the last six months of his life 1 
prescribed for him. When I first examined him, the 
abdomen was distended in the hypogastric and ingui- 
nal regions, and the epigastric was very much con- 

4* 



38 CHRONIC DISEASES OF THE 

traded, with a transverse contraction about two 
inches above the umbilicus. He had diarrhoea almost 
constantly, and was much emaciated. The colon, 
from its enlarged condition was easily traced through- 
out its entire course, though less at that time than at 
any time previous, except, perhaps, during the first 
eighteen months. His physician, who attended him 
during; the attack of fever, told me his bowels had 
been tympanitic and very tender, which was relieved 
by a blister. 

The appearance twenty-four hours after death was 
very singular. One half of the lower portion of small 
intestines I found in the pelvic cavity with three con- 
tracted portions of the ileum. The first contracted por- 
tion three feet from the ileo-ceecal valve, was four inches 
in length and would barely admit a quill to pass. Ten 
inches from the first, was the second contraction, 
which was two and a half inches in length, with simi- 
lar appearances — the third contraction, eighteen inches 
distant from the second, was nine inches in length, and 
in half its extent, was similar to the first. This con- 
tracted part rested with its middle over the left margin 
of the promontory of the sacrum, to which slight at- 
tachments had formed. All the contractions appeared 
to have been the effect of acute inflammation in the 
early part of the disease, as there was no appearance 
of ulceration or softening in the contracted portions. 
The colon was enlarged throughout, and ulcers in 
various parts, with thickened and softened portions of 
the membrane. The sigmoid flexure in the pelvic 
cavity was enlarged and full of ulcers. The rectum 
was filled with hemorrhoidal tumors, so large in some 
places as almost to close the passage. Several of the 



VISCERA OP THE ABDOMEN. 39 

tumors had small rasped ulcers on them. The trans- 
verse colon, at the lower portion, rested across the 
second lumbar vertebra — the spleen was near the 
centre of the left kidney — the liver was so far sunk as 
to bring its lower margin in contact with the os ilium. 
It was enlarged, and had six or eight white tubercular 
formations of a hard fibrous texture. The stomach 
and duodenum had several softened stripes on the mu- 
cous membrane. The small intestines were very 
much congested, and the mesenteric glands enlarged ; 
two of which, contained about one drachm of cheesy 
looking pus. The peritonaeum in various parts had 
marks of inflammation, from slight fibrous adhesions ; 
but none of recent appearance. The bladder was 
thickened and contracted, and on the inner surface, 
had a flocculent jelly-like mucous lining. The mu- 
cous membrane of the lungs was somewhat softened, 
with but a few tubercular formations in the left bron- 
chia of very small size. 

The appearance of those who died of gastroen- 
teritis were as follow s : — The first case was a patient 
aged thirty-seven, of sedentery habits. The colon 
was considerably enlarged in the sigmoid portion, and 
covered with small ulcerated spots, with an abraded 
appearance of the mucous coat. In the descending 
portion, were slightly thickened appearances in the 
foldings of the inner membrane. The transverse por- 
tion at the centre, had fungus looking spots consider- 
ably elevated, all of which were easily removed with 
the back of the scalpel. In this group, were two or 
three ragged ulcers ; each angular portion was thick- 
ened and condensed in all its coats. The ascending 
colon was much enlarged, with ulcers of different 



40 CHRONIC DISEASES OF THE 

shapes and sizes. The ceecum was also enlarged and 
ulcerated with similar ulcers in and near the ileo- 
cecal valve. A portion of the small bowels was 
found in the pelvis highly congested, with a thickened 
appearance of every coat. The mucous coat had an 
abraded appearance, and in some parts, elevated and 
softened spots which continued throughout the intes- 
tines, contained within the pelvis. At or near the 
division of the ileum and jejunum, was a contracted 
portion, which was about three inches in length, the 
caliber being only half its original size. The mucous 
membrane appeared healthy in the upper portion until 
it terminated in the duodenum, which was covered 
with dark red patches, and by a few ulcers at the 
lower angle. The stomach was flaccid and attenu- 
ated, with its mucous coat irregular, and of a mottled 
ash color ; but not softened. The liver was of a 
bronze color, with the exception of the parts to which 
the blood had gravitated. The lungs, on the mucous 
coat, were marked with chronic softenings, having 
many sacs or distended air cells with slight infiltra- 
tion. The heart was apparently healthy. This case 
had been under several physicians, two of whom had 
treated it as a disease of the liver, — a third informed 
me it was a disease of the heart. 

The two following cases have been selected in con- 
sequence of their morbid lesions being peculiar and 
extensive. They had been treated by other physicians 
as dyspepsia, diseases of the heart and liver. The 
examination was made eighteen hours after death in 
one, and twenty-four in the other. The first was aged 
thirty-nine — habits active and temperate. The origin of 
the disease was attributed to an attack of intermittent 



VISCERA OP THE ABDOMEN. 41 

fever, which entailed constipation. From the attack un- 
til the time of his death, was five years. On opening the 
abdomen, the lower portion of the small intestines and 
sigmoid flexure of the colon, were found in the true 
pelvic cavity. The transverse colon and omental pro- 
cesses, were depressed to the lower boundary of the 
abdomen. The mucous membrane of the colon, one 
third of the small intestines, a part of the stomach, 
and spots in the duodenum, had a pale ash color, and 
an attenuated appearance, except the mucous follicles, 
which were elevated, and as large again as they 
should be. The sub-mucous and mesenteric blood- 
vessels remarkably large. The symptoms, with the se- 
cretions, would have induced the belief that the colon 
was covered with ulcers, but none were found within 
the alimentary canal. The brain, lungs, and heart, 
had a normal appearance. The liver was enlarged, 
lax and soft, having a leaden or bronze color. Two 
months previous to death I was in attendance with the 
family physician, when I found the emaciation ex- 
treme. He exhibited all the marks of tuberculated 
consumption, except the cough. I examined the se- 
cretions from the bowels every other day, in which I 
detected muco-purulent matter. From this fact and 
from the appearance of the mucous membrane, blood 
vessels and follicles, I inferred that muco-purulent 
matter had been secreted, either by the membrane or 
follicles, or both. 

The second case, aged twenty-seven — habits ir- 
regular and at times intemperate. Previous to death 
I was called in consultation every other day during one 
month. The symptoms- like those of consumption, 
with slight cough and distressing dyspnoea. Dis- 



42 CHRONIC DISEASES OF THE 

charges from the bowels and lungs muco-purulent. 
One year previous to death he had constipated bowels 
for three or four days at a time, alternating with mu- 
cous diarrhoea for ten or twelve days, with irregular 
appetite. Examined twenty-four hours after death: 
the small intestines, sigmoid flexure, transverse colon 
and omental processes, were nearly in the same con- 
dition as those of the preceding case. The mucous 
membrane of the lower third of the ileum, was soft- 
ened in spots, and covered with small ulcers. The 
ascending colon interspersed with thickened stripes 
and small ulcers. The mucous coat of the transverse 
portion was covered with ash colored spots, and half 
a dozen ulcers in the centre. The entire coat was 
thickened at the right angular process. The stomach 
in the left extremity had ash colored spots, and small 
ulcers were observed in the lower angle of the duo- 
denum, with softening and stripes. The sigmoid 
flexure was ulcerated throughout. Liver enlarged, 
and of a dark firm texture. Heart natural. Lungs 
infiltrated partially. Mucous coat had an abraded 
appearance, with some of the air cells enlarged, and 
in the summit of the left lobe, small millet-like tuber- 
cular formations. This case had been treated for 
dyspepsia by several physicians. 

Of the two cases of bilious colic I examined, the first 
case, aged twenty-three, in which the bowels were con- 
stipated three days previous to the attack. The day 
preceding, danced at a barbecue on the fourth of July. 
First symptom was nausea, with bilious vomiting; 
hands and feet cold. From the commencement, as 
stated by the physician in attendance, and by the 
family, the nervous system was much disturbed with 



VISCERA OF THE ABDOMEN. 43 

spasmodic contraction of the muscles of the abdomen 
and extremities, and with despondency, &c, which 
rapidly increased until the fatal termination, about 
eighteen hours after the vomiting commenced. Twelve 
hours after death, the organs of the abdomen were 
examined, and the sigmoid flexure, and one-third of 
the small intestines were in the lower pelvic cavity. 
The sigmoid flexure and descending colon had been 
emptied by the injections, but were distended with 
gas. The transverse and ascending colon were im- 
pacted, and distended, and marks of inflammation 
were on the outer coat of the bowel. The small in- 
testines in the pelvis were congested, and the perito- 
naeum, stomach and duodenum, showed strong marks 
of inflammation throughout. There was an intus- 
susception in the lower third of the ileum, where 
it was twisted one inch in length. Through this 
no medicine had passed. The speedy termination 
of life was from inflammation, and doubtless the exer- 
cise produced the displacement, nnd inflammation was 
accelerated by the free use of ardent spirits. 

The second case, aged forty-one years — habits regu- 
lar. Previous to the attack was engaged in raising 
heavy timber. The attack commenced with flatulent 
colic. The examination was made fifteen hours after 
death, and the small intestines found in the pelvis, 
with the sigmoid flexure and transverse colon distended 
and the latter sunk down at its centre. The sigmoid 
flexure and the descending portion were completely 
emptied by the injections, while the ascending colon was 
distended and impacted. The small intestines in the 
pelvic cavity were congested and twisted in the middle, 
and marked with acute inflammation. In this case 



44 CHRONIC DISEASES OF THE 

the result was obviously owing to obstruction in the 
veins which became greatly distended, while the capil- 
laries from which they proceed, became congested, 
having a dark grumous aspect. The small intestines 
were much distended with gas. The ascending colon 
enlarged and distended. The transverse colon, duo- 
denum and stomach inflamed ; at the right angle of 
the transverse colon, from the depression of its centre, 
the caliber was reduced to at least one half its natural 
size ; at this point there were marks of inflammation 
of the peritonaeum, and the mucous coat was similarly 
marked. The history of the case I was unable to ob- 
tain. I was told he had been frequently attacked 
by colic, which was generally relieved by an emetic 
or a large dose of oil and turpentine. 

From these, and other cases of a similar character, 
which have been examined or come under my notice, 
I am warranted in the conclusion, that displacement, 
or gravitation of the abdominal viscera, is a prolific 
source of the diseases enumerated at the head of this 
essay ; and although it is the cause of many of the ills 
of life, it is itself the effect or consequence of the de- 
bility of the abdominal muscles ; which also is an effect 
of various causes, as sedentary habits — too long stand- 
ing — over fatigue — cold — over distension and gravi- 
tation of the solids and fluids. 

The effects of such displacement are numerous and 
various, since the muscular and nervous svstems are 
involved. They are briefly as follows : 

I. Obstruction of the bowels and blood-vessels. 

II. Debility of the muscular and mucous coats of the 
stomach and bowels, and diminution of vascu- 
lar contractility. 



VISCERA OF THE ABDOMEN. 45 

III. Deranged action of the liver, spleen, pancreas, 
&c. 

IV. Imperfect digestion. 

V. Premature decomposition of aliment, generating 

gas, which distends the digestive tube, and espe- 
cially the colon. 

VI. Gastric irritation from acidity, in which the liver 
and brain participate sympathetically. 

VII. Imperfect assimilation, by which the consti- 
tuents of the blood are modified to a greater or 
less extent, which alone is sufficient to impair 
the functions of the entire animal economy. 

These conditions, then, the results of displacement, 
may be the direct or indirect source of almost all the 
diseases which affect mankind, not excepting epide- 
mics ; — to which they render the system more sus- 
ceptible by reducing the standard of health below par. 

The causes, therefore, being known, the treatment 
is simple, as the indications are easily made out ; and 
one of the most important is to remove the antecedent 
cause, and restore the displaced organs to their primi- 
tive position, and give support to the abdominal 
muscles, whose normal condition is requisite to main- 
tain their restoration. 

Mechanical agency, then, being the first indication, 
medicinal agents may be given in accordance, as the 
different stages of the disease may indicate. 

But as my views may be singular as to what are the 
real indications, and the particular medicinal agents 
best adapted to fulfil them, I will give a desultory 
sketch of my mode of treatment, to cover the entire 
group. In ordinary constipation, I invert the body 

5 



46 CHRONIC DISEASES OF THE 

or elevate the hips occasionally, apply a supporter, 
direct vegetable diet, with bran bread, stewed fruit, 
&c. and regular and punctual attempts at stool, at a 
certain hour each day, with gentle exercise, aperients 
and alteratives. 

These are some of the means I use, in addition to 
those usually employed in the treatment of the dis- 
eases located in the cavity of the abdomen ; and from 
these general desultory hints, my theory, with what 
follows in the way of treatment, will be understood. 
The success which has crowned my efforts, has far 
exceeded my expectations, and convinced me of the 
truth of the theory, and utility of the treatment based 
upon it. Hence my desire to give to the profession 
what has been of signal service to my patients for 
twenty-one years ; though in these remarks, while I 
may incur the imputation of egotism, I have been 
actuated by the sincerest motives. 

Dyspepsia, which is the result of functional derange- 
ment and gastric debility, arising from the nervous 
and capillary systems, is also to be relieved by mild 
aperients, diet, and the application of suitable sup- 
porters or suspensory jackets. But before the reme- 
dies are applied, the patient should invert his body, for 
the purpose of restoring the organs to the place where 
nature intended they should perform their functions. 
If confined to the recumbent position, the object may 
be accomplished, by elevating the hips, and flexing the 
thighs upon the body for fifteen minutes every twenty- 
four hours, or, by inverting the body one minute. 
Then if the action of the bowels is not regularly main- 
tained by the supporters, diet and exercise, a half grain 
of ipecacuanha and thirty grains of soda should be 



VISCERA OF THE ABDOMEN. 47 

given two or three times a day ; or, if there is much 
irritation, one grain hyoscyamus, with half grain 
ipecacuanha may be given at bed time. This pill, 
with sponging the body night and morning with equal 
parts of whiskey and water, I have found best for 
soothing the irritability of the system. The saturated 
tincture of Indian hemp is also a valuable medicine, in 
this form of the disease, to regulate the boAvels, and 
restore the functions of the skin and kidneys. From 
fifteen to sixty drops, three times a day, may be given. 
For functional derangement of the liver, the extract 
conium and a decoction of taraxacum, in addition to 
the blue pill (which should not be pushed to affect the 
general system,) are the most efficient agents. 

Indigestion, as described by most of our medical 
writers, includes chronic gastritis, enteritis and hepa- 
titis. The indications of the advanced stages are in- 
tended to meet the four diseases. It seldom continues 
long without being combined with functional derange- 
ment of the liver, the skin and alimentary canal. 
Where the skin and eyes, with the appearance of the 
stools, exhibit a failure in the functions of the liver, 
the use of blue mass, extract conium and decoction of 
dandelion, will generally give prompt relief— four 
grains blue mass to one of conium, every other night, 
with a strong decoction of dandelion, may be given in 
three equal parts during the day, until the functions of 
the liver are restored. Three ounces of the root in a 
quart of water boiled down to a half pint, will be of 
sufficient strength for the decoction. If the bowels 
are tardy under the influence of the pill, a half grain 
of ipecacuanha may be added to each third of the 
decoction, until the bowels are moved once or twice 



48 CHRONIC DISEASES OF THE 

each day. Mercury should not be used to affect the 
general system. Alkalies are a good palliative to remove 
the acidity of the stomach, with Dover's powder at night, 
if irritability indicate its use. Acute or sub-acute inflam- 
mation of the mucous membranes of the stomach and 
bowels are not infrequent, with tenderness on pressing 
upon the part, which sometimes requires leeching or 
blistering. In such cases, I have found the morbid irri- 
tability subdued by doses of ipecacuanha, combined 
with carbonate of soda, during the day, and Dover's 
powder at bed time. In chronic disease of the intestinal 
canal or liver, free purging should be avoided. Calomel 
in full purgative doses is required in the treatment of 
chronic diseases of the liver, but rarely. Where the 
gastric irritation or chronic lesions of the mucous 
membranes, or liver, establish febrile or inflamma- 
tory symptoms, the diet must be of mild character, 
without animal food or stimulating drinks. In chronic 
hepatitis there are a great variety of morbid appear- 
ances described in medical writings: but we find the 
treatment to resolve itself into one general code, which, 
in the inflammatory stages, is leeching, cupping, anti- 
monials, moderate mercurial courses, aperients, blis- 
ters, tartar emetic, opium and diuretics, which I have 
found serviceable, and would, in addition, recommend 
the saturated tincture of apocynum cannabinum, in 
doses to keep the bowels in a soluble condition — 
given in a solution of dandelion. Where the stomach 
and bowels are feeble from the irritability of the sys- 
tem, the tincture should be given in a cold infusion of 
the prunus Virginiana. The bark should be procured 
fresh every day. Two ounces bruised to the half pint 
of water, and taken during the day. These, with the 



VISCERA OF THE ABDOMEN. 49 

proper attention to supporting the viscera of the abdo- 
men, will be found adequate. The healthy functions of 
the skin should also be attended to, as well as the in- 
ternal organs, owing to the intimacy of the capillary 
vessels and nerves, which are dependent upon such 
healthy action, and seem to receive the first shock from 
the numerous morbific agents. Experience has taught 
the profession that our hope for a favorable termination 
of the disease, is dependent on the healthy movements 
of these two systems. But as the treatment of chronic 
diarrhoea, in the remaining indications, will apply to 
gastro-enteritis, 1 will finish under that head. 

It is, however, understood, that the first effect of 
inflammation on an organ, is to suspend the secretion 
of the tissue, or produce a diminution of that which is 
unhealthy; but this rule does not hold good in the 
mucous membranes of the stomach and bowels, as 
we find the worst forms of the disease produced 
by inflammation. Diarrhoea may be brought on by 
fright, unwholesome or indigestible food, diseased 
biliary secretions, or any irritating cause acting upon 
the mucous surfaces, through the capillary vessels and 
nerves. For instance, cold water suddenly thrown 
upon the surface will frequently act as an excitant to 
the internal mucous membrane. 

Thus, from this pathological description, it will be 
seen that chronic diarrhoea is derived, in some, from 
irritation, constipation, gravitated viscera, irritated 
condition of the mucous surfaces, and inflammation, 
which may terminate in chronic gastro-enteritis. 
Hence chronic diarrhoea is a mere symptom of primary 
internal disease. 

The indications, in the first named list, must be 

5* 



50 CHRONIC DISEASES OF THE 

considerably modified, if it be produced from unwhole- 
some food. A gentle laxative, with the use of some 
one of the alkalies, will be sufficient to remove it. Or 
if from cold, warm bath with flannel worn next the 
skin— if from acrid secretion of bile, a small dose of 
calomel and opium — if from constipation and the 
gravitated viscera, or fluids, reverse the body, or ele- 
vate the hips, so as to replace the bowels, and apply a 
supporter to prevent the gravitation, and correct the 
secretions, with a small dose of calomel, ipecacuanha 
and opium. If the disease is derived from irritating 
substances contained in the alimentary canal, a dose 
or two of oil, or jalap and cream of tartar, will gene- 
rally remove the cause. But if the diarrhoea should 
be dependent upon acute or chronic inflammation, in 
like manner, the cause must be removed. If acute, 
blood taken from the arm will be necessary ; but if the 
patient should be feeble or reduced, leeches should be 
applied and followed by warm fomentations, repeated 
until the active pain is reduced ; after which a blister 
and alkalies, to correct the secretions, calomel, ipe- 
cacuanha, opium and Dover's powder. But where the 
remedies, with gum water, absorbents and astringents, 
fail, I have been able to control the disease by a 
flannel roller and pledgets. By the roller, and wedge- 
shaped pad, with direction to the patient to lie on the 
right side, or back, with the hips somewhat elevated, 
and the thighs flexed on the body, the peristaltic and 
vermicular movements will be checked, and relief will 
follow. In acute or chronic inflammation, I have 
found the roller an efficient agent, as it checks the 
movement of the inflamed viscera, and produces the 
quietude so desirable in the treatment. 



VISCERA OF THE ABDOMEN. 51 

Bandages are as strongly indicated in inflammation 
of the bowels as they are in a fractured limb, and in my 
practice I have derived signal satisfaction from their 
use ; but it is understood they are not to interfere with 
such other remedial agents as may be deemed neces- 
sary. It has been a rule with me to move the bowels 
once in twenty-four to seventy-two hours, unless 
urged to more active treatment by the pain. If the 
secretions be acrid, and continue to irritate, the band- 
age should be removed and mucilaginous injections, 
or a dose of oil administered. After which the band- 
age may be replaced, and small doses of Dover's powder 
given and repeated every six or eight hours. By pur- 
suing this course, with the requisite attention to the 
skin, and the constitutional alteratives, the acute, or 
sub-acute inflammation will be subdued and the diar- 
rhoea checked. 

In addition to the remedial agents thus recom- 
mended, I have found, after correcting the secretions, 
that by applying a Burgundy pitch plaster to cover the 
entire abdomen, with the bandage over it, the disease 
with all its irritating symptoms would speedily yield. 
This plaster, with a supporter, on the true dyspeptic, 
will relieve without the application of medicine. In these 
diseases, it is of much importance in the treatment, 
where the supporter is dispensed with, on account of 
the demand for the roller to direct the patient not to 
incline forward on the close stool, as it changes the 
axis of the body and permits the bowels to pass into 
the pelvis, which may re-establish irritation and inflam- 
mation. Hence the sedentary victim to misplaced 
bowels, and hence also the fashionable names and 



52 CHRONIC DISEASES OF THE 

the more fashionable treatment for this old-fashioned 
disease. 

Chronic peritonitis is a disease so insidious in its 
attacks that it rarely becomes the object of treatment 
until it is incurable. It is, in my opinion, to be traced 
more frequently to constipation, and the consequences 
of misplacement, than all other causes, except the 
sequel of inflammation, after confinement. In my 
practice I have had but few cases of recent occurrence, 
and from the successful termination, I found them as 
curable as any of the chronic diseases, except that 
more time was required where effusions had taken 
place. In the incipient stage, it required depletion, 
either general or local, counter irritants, alteratives, 
diuretics, diaphoretics, with aperients and purgatives 
of calomel, compounded with ipecac, opium, or Dover's 
powder, and carried off by oil and spirits of turpentine. 
After the inflammatory action has been reduced to the 
blistering point, a large blister should be drawn, and 
on the second day dressed with mercurial ointment 
and the Burgundy pitch plaster, with a suspensory 
jacket over it. The effect of this mercurial plaster 
on the constitution must be observed, and removed if 
it excite the salivary glands, or if the irritation of the 
blister becomes too great, warm fomentations, or 
emollient poultices should afterwards be used to abate 
the irritation or inflammation brought on by the 
plaster. But when the irritability of the constitution 
forbids a blister, the tartar emetic mixed with the mer- 
curial ointment, will answer the purpose, with the 
pitch plaster. Where effusion has taken place, which 
exists to a greater or less extent in every case, the 



VISCERA OF THE ABDOMEN. 53 

bandage should be used occasionally with or without 
the suspensory jacket. The object is to abate the 
effusion by accelerating the action of the absorbents. 
Mild laxatives of a diuretic character will be required 
during the progress of the disease. For this purpose 
the saturated tincture of the apocynum cannabinum, 
given in doses from half to a drachm, twice or thrice 
a day, mixed in the decoction of dandelion, will be 
found efficient. The extract conii, and hyoscyamus, 
may be dissolved and given in connection with the 
tincture. The former, where the absorbents fail to 
stimulate the functions, by the mecurial ointment and 
bandage, to be added where the irritability of the 
system indicates its use. I have found the conium a 
good adjunct with the mercurials. During the treat- 
ment, the integrity of the skin should be maintained, 
and occasionally a free use of jalap and cream of tar- 
tar, will be indicated and found of service. 

Splenitis is alike the offspring of constipation, 
gravitated viscera, and the sequel of intermittent and 
remittent fevers. The altered condition of the organ 
is various, but the most common, is a softening of the 
structure, and enlargement from intermittent and re- 
mittent fevers. Suppuration and ossification have been 
met with. The treatment, however, is pretty much 
the same as in the preceding diseases, viz. : cupping, 
leeching, mecurials, tartar emetic ointment, laxatives, 
supporters, &c. In enlargements from fever, I have 
found no remedy more useful than the compound tinc- 
ture of the apocynum cannabinum, given in doses three 
times a day sufficient to augment the action of the 
bowels above the healthy condition. Where febrile 



54 CHRONIC DISEASES, ETC. 

symptoms supervene, antimony in small doses will 
soon control the heart and arteries. The extract 
conii, given in combination, with blue mass is fre- 
quently of service. 



STRUMOUS HABIT 



The strumous habit, or a predisposition to scro- 
fula, is a constitutional tendency which frequently 
appears in children as a hereditary diathesis. But 
this is not^its only source. The causes to which the 
various writers refer, are a distempered state of the 
atmosphere, deficient and unwholesome food, with the 
sequel of the various exanthemata. From observa- 
tion, however, I believe that the most frequent cause 
of strumous disease, except that of inheritance, is 
the gravitation of the viscera of the abdomen and 
of the fluids to the most pendant parts of the body, 
and eruptive diseases which have their origin in 
the deranged condition of the digestive organs. So 
far as I have been able to judge from the external 
appearances of scrofulous families, in relation to com- 
plexion, and colour of hair, I believe all complexions 
are alike subject to scrofula, and that it is owing most 
frequently to the circumstances which surround the 
individual that call it into action. 

The best external sign of scrofula that I have been 
enabled to observe, is theuniformly lax and feeble con- 
dition of the muscular system. For although the cellu- 



56 STRUMOUS HABIT. 

lar membrane may give the appearance of health, the 
digestive organs, deranged by difficult dentition, sum- 
mer complaint, or any other cause, show this to be 
only apparent, not real. On examination, we find an 
irregular appetite, at times voracious, at others de- 
ficient. In such constitutions it will invariably be 
found that the lower half of the abdomen is tumid. 
The weakened condition of the muscular system re- 
quires but little derangement, or exertion, to prostrate 
the muscular parts of the abdomen, and consequently 
derange or overpower the mechanical functions of 
those muscles. Hence the frequency in such cases, of 
the bowels gravitating to the pelvic cavity which gives 
rise to further derangement of the digestive organs. 
It also establishes irritation in the mesentery, and de- 
ranges the capillary vessels, glands and nerves, by 
which, with the gastric derangement, an increased 
vascular action is established which soon augments 
the difficulty in the already debilitated capillary vessels, 
which are below the point of resisting the vis a tergo of 
the heart, and confirms the congestion upon the bow- 
els. This fact has been fully demonstrated by the cases 
of a number of children whose bodies I have examined 
after death, and by a number of living patients who have 
been relieved by the appropriate mechanical support. 
In each the bowels were displaced, and upon the small 
intestines, tubercular formations with congestion were 
found. It had been my belief that the diseases arising 
from scrofulous habit, were brought into action more 
frequently from derangement of the digestive organs, 
than from any other cause, and in order to collect the 
facts upon the subject, I commenced to investigate 
all the families within my reach, laboring under any 



STRUMOUS HABIT. 57 

form of the disease, and by examining the brothers and 
sisters of the afflicted, I satisfied myself of the soft 
texture of the muscular system, and the pendulous and 
tumid condition of the lower part of the belly. I 
also learned that both parents, and children, were 
constantly suffering from reverses of appetite, or ir- 
regularity of the bowels, and that the causes were 
manifestly owing to the original weakness of the mus- 
cular fibres, which were not sufficient to enable them 
to perform their functions. 

But in describing the characteristic marks indi- 
cating scrofulous diathesis, the writers on the subject 
have given only the condition of the patient after the 
disease has given evidence of its local existence, in- 
stead of making us acquainted with the temperament 
and habit of the body antecedent to the local mani- 
festation. All parts of the system are liable to 
scrofulous affections. In some it may appear first 
with a tumid belly, thickened and chapped upper lip, 
extending to the alas nasi, an enlargement of the 
lymphatic glands, particularly those of the neck, and 
not unfrequently the eyes were affected. In others, 
tubercular formations appear in the lungs, and in 
others of the same family it makes its appearance in 
the joints. In my practice this fact has presented 
many illustrations, and I have frequently met with 
cases where it was almost impossible to determine 
whether it was cutaneous, and dependent upon the de- 
rangement of the digestive organs, or the manifesta- 
tions of scrofulous diathesis. Cutaneous diseases not 
belonging to the order of exanthemata, and deriving 
their origin from a derangement of the organs of the 

abdomen, are more liable to be mistaken for scrofula 

6 



58 STRUMOUS HABIT. 

than any of the other diseases. Their history, as 
found in most of the medical books, is worthy of the 
closest scrutiny. By it the reader will discover the 
importance of distinguishing the scrofulous eruptive 
diseases from those which have their origin in other 
sources; and also the intimacy of the functions of the 
mucous membrane and the skin, which appears to be as 
closely connected as the capillary vessels, and nerves. 
But when we view these cutaneous diseases in connec- 
tion with the functional derangement of the internal 
viscera, in some the stomach, others, the liver and 
lungs, and others again in the brain- indelibly marked 
with the ravages of functional derangement, or or- 
ganic lesion, it will be very clear that cutaneous 
diseases are well calculated to engraft upon many 
constitutions the scrofulous habit. 

Tuberculated consumption, from its history, and 
the analysis of the tuberculous matter, is a disease 
dependent upon strumous diathesis, in the greater 
number of cases. But this is a controverted point 
with the profession, and as I am inclined to believe, 
that whenever a careful analysis of the tuberculous 
matter, as found deposited in the mesenteric and 
lymphatic glands, in and upon the brain and lungs, is 
resorted to, with the necessary allowance for the tis- 
sue upon which the matter was deposited, which 
physiologists know, will influence the deposit in pro- 
portion to the constituents of the tissue upon which 
the deposit was made, the matter will be found to 
be the same throughout the system, I infer the word 
struma is properly applied to this class of disease. 
Its progress and duration, we find, are various. In some 
it is developed in infancy, whilst in others the consti- 



STRUMOUS HABIT. 59 

tutional tendency remains dormant until puberty or 
a later period, before it is called into action. Some 
individuals who are affected in the lymphatic glands, 
continue so till the end of life without experiencing 
any particular suffering; but in strumous constitutions, 
one or more of the vital organs, in the early part 
of life, becomes the local seat of the disease. The 
first manifestations, however, are more frequent at the 
time of dentition, and it is then that parents should 
understand the condition of their child, and receive 
the instructions for its cure. Phthisis is looked upon 
as a complicated disease, owing to the number of 
organs or tissues liable to the affection during its pro- 
gress, and the uncertainty of the tissue or organ that 
was first the seat of the morbid action. These com- 
plications, when examined, will be found nothing more 
nor less, than the yielding of the weaker parts of the 
system, and so on in succession, until the analogous 
tissues, dependent upon the strumous habit, are put in 
motion. Tubercular or scrofulous phthisis, is an ap- 
propriate name for at least nine out often cases; and 
as it has already been stated, that a lax feeble muscu- 
lar fibre is one of the characteristics of the disease, 
I quote from Professor Geo. B. Wood, to show that I 
am not alone in this position. In vol. ii. page 104 of his 
valuable work on the Practice of Medicine, he says, 
" The predisposing cause decidedly the most influen- 
tial of those so far as known, is inheritance. Phthisis 
is pre-eminently a hereditary disease.'' On page 105, 
" Whatever has a tendency to produce permanent or 
long continued debility, will generate in some indivi- 
duals the consumptive • diathesis ;" and page 106, 
" The disease is much more common in women than 



60 STRUMOUS HABIT. 

in men. It occurs in them, too, at an earlier age, and 
in general is more rapid in its progress." There are 
various causes for this difference. In the first place, 
the original organization of the female is more deli- 
cate, and consequently exposes her more to diseases 
of relaxation and debility. 

Another of the causes of this fatal disease is ascri- 
bed by many writers to sedentary habits ; but as 
the consequences are of a two-fold character, first 
in debilitating the muscular system, and secondly in 
establishing constipation from debility, it will be found 
that either or both is but the principle upon which the 
latent diathesis is put into action. After the system 
becomes debilitated a few degrees below the strumous 
standard, the bowels gravitate every day, and only 
recover their natural position by the recumbent pos- 
ture during the night; but eventually the attachments 
become elongated, with an increase of debility in the 
walls of the abdomen, which of course allows but a 
partial restoration, and upon resuming the erect posi- 
tion, the bowels again fall into the cavity of the pelvis, 
and eventually prostrate the entire system. If we 
examine the symptoms and feelings of an individual, 
laboring under hernia, we find that his strength is sub- 
dued as soon as the bowels descend from their natural 
postion. And is it not reasonable to suppose, that the 
gravitation of the bowels into the pelvic cavity, would 
produce the same effect ? But if there are any who 
may regard these remarks as establishing an absurd 
hypothesis, let them examine their own abdomens, 
night and morning, when they will be enabled to estab- 
lish the truth or the fallacy of this position. 
L The human system is continually surrounded by 



STRUMOUS HABIT. 61 

causes which tend to interrupt the healthy functions 
of life. And if it were not that the animal organiza- 
tion is endowed with a resisting power against the 
influence of those morbific agents, man would not be 
enabled to live amidst the multiplicity of causes that 
conspire unceasingly to his destruction. Hence, it is 
of the utmost consequence that this vital force should 
be sustained, and as conservators of the general health, 
it is the business of physicians to determine whe- 
ther the means of protection shall be chemical or 
mechanical, or both. If there is reason to doubt this 
position, upon what does it really depend? If not, 
what have we been taught by the physiological laws 
of life, which I understand to be the harmonious action 
of the vital and mechanical functions, as arranged by 
the Creator of the universe to the fulfilment of a special 
end ? In my opinion, whatever is calculated to en- 
feeble the chylopoietic organs, or weaken the mecha- 
nical functions, diminishes the vital resisting force, 
and consequently when we find the citadel of the eco- 
nomy encroached upon, and the bastions of the fortress 
subdued, the enemy to vitality will make an easy prey 
of the balance. Hence, is it reasonable that the 
common elements which contribute to our existence 
should be capable of producing so many maladies, if 
the system has not been weakened by some remote 
cause ? To me the facts are plain, and as I believe 
with the majority of the medical world, that strumous 
diathesis is an appropriate term for all classes of scro- 
fulous and tubercular diseases, I shall adopt this view 
in the subsequent part of the treatise. 

In all children of strumous diathesis the muscular 

system is of a soft lax texture ; so much so, as to be 

6* 



62 STRUMOUS HABIT. 

easily detected when contrasted with other children 
free from hereditary taint. 

The one with scrofulous diathesis, in a large ma- 
jority of cases, will be found to have an unusual de- 
velopment in the cellular membrane, giving a round, 
plump appearance to the entire system ; but when 
examined by the touch, these appearances will be 
found to depend upon the cellular and adipose mem- 
branes. The apparent plumpness and beauty may 
continue uninterrupted, if the bowels should not from 
fatigue be permitted to gravitate and derange the 
digestive organs ; or if difficult dentition with other 
causes, should not derange the functions. The scro- 
fulous or strumous diathesis, I understand to be an ex- 
cess of white over the red fluid, which I believe is the 
received opinion of the profession. This being ad- 
mitted, what would the physiologist think of the 
result of such disproportions between the organic 
elements from which the entire organism is composed, 
when it is known that each tissue, or organ, is con- 
structed from one or more of the organic elements ? 
Would it not be reasonable, understanding as he does 
the laws of life and the true analysis of the tissues and 
organs furnished with the best supplies in accordance 
with the parts, which organ would be the best developed ? 
And is this not the case in strumous diathesis ? In the 
examination, I have found all the white and translucent 
tissues, with the glandular system, highly developed, 
and all of them, with more than usual activity in their 
several functions ; but is this the case with the muscu- 
lar system ? My practice during thirty years has not 
presented a single instance by which the reverse could 
be proven. 



STRUMOUS HABIT. 63 

Fatality. — The medical statistics present the fact 
that the number of deaths from scrofulous habit 
is greater before nine years of age. After which 
the deaths are comparatively few, until after puberty; 
but in this interval, the person endowed with the taint, 
is liable to cellular abscesses, lymphatic enlargements, 
diseases of the skin, eyes, and also when attacked 
wdth febrile disease, is in great danger of losing 
his life. From the age of puberty, say sixteen to 
twenty-eight in the female, and from twenty-one to 
thirty-three in the male, is the next fatal period. 

Post mortem Appearances. — From the examinations 
in childhood, morbid lesions are found upon the mucous 
membranes, with mesenteric enlargements ; and in 
four out of twenty cases examined, at the summit of 
the lungs, millet-like tubercular formations were found ; 
and six of the whole number, had some one of the me- 
senteric glands softened; nine had tubercular forma- 
tions on the small intestines, and had their bowels 
more or less agglutinated ; but in all the mucous 
follicles to a greater or less extent, ulcerated, — the 
colon being the principal seat of the ulcers ; the small 
intestines and the mucous membrane of the lungs had 
a phlogosed appearance ; within the stomach, seven 
had rose-colored spots, and of the twenty examined, 
sixteen had the small intestines and sigmoid flexure in 
the lower pelvic cavity. 

Tubercular deposition in adults is found in every 
cavity, and it appears that no part of the system is 
free from the deposit ; but the fatal seat is in and 
upon the lungs and viscera of the abdomen. In the 
chest and abdomen of some of the cases examined, 



64 STRUMOUS HABIT. 

the organs were completely studded with tubercular 
deposition. The theories advanced by the different 
pathologists, on the origin of tubercular deposits, are 
various ; some contending that it is the result of inflam- 
matory action, while others insist that it arises from 
infiltration; but as theories and controversies are 
foreign to my purpose, I shall confine my essays to 
clinical observation. 

In relation to tubercular formation in adults, it ap- 
pears to me that the deposit is an effort of nature, as 
in childhood, to balance the organic elements of the 
blood. From the earliest period in life to adult age, 
we see that the over amount of white fluids is ex- 
pended upon the cellular membrane, or analogous 
tissue, and from the abundance of nutritious matter, 
the appearance is kept up, and the organic elements 
of the blood are regulated in conformity with the laws 
of life ; but at the same time, it gives through the nu- 
tritive vessels, a disproportion to the growth and 
strength of the tissues composing the organism. By 
this nutritive expenditure, one-third or more of 
those laboring under strumous diathesis are kept in 
health to a later period in life, but in the remainder, 
the loss of balance between the constituent elements 
deranges the digestive organs, and in infancy, carries 
them off, notwithstanding the liberal efforts of nature 
to retain them. 

At adult age, agreeably to the natural laws, the 
growth of the system is perfected, and no further de- 
mand is made upon the nutritious system than is 
requisite for the natural waste of the economy; but 
it leaves nature with a large amount of white fluids in 



STRUMOUS HABIT. 65 

the circulatory system. This disproportion between 
the constituents is a source of derangement through- 
out the stages of life, as is manifested in infancy by 
the morbid assimilatory and nutritious processes. The 
infant, by inheritance, may be justly said to be born in 
a pathologic state, which is manifest in the growth of 
one set of organs, and the want of proportion in the 
other, which is attributed to the peculiar virus or 
condition of the organism. All the writers on scro- 
fula have observed, and remarked upon the unusual 
sagacity and early development of the intellectual 
faculties attendant upon this peculiar diathesis, and 
the organ to which the function is assigned, of gene- 
rating our ideas, in its constituent, is formed from the 
white fluid. The same unnatural strength is observa- 
ble in the digestive organs until thwarted by other 
causes, and it appears all those exalted movements 
have their origin in this virus, acting as a stimulant 
favorable to the assimilated functions destined to pre- 
side over the fluids, and all the functions susceptible to 
the specific influence of this stimulus. All of which 
have their origin in a morbific cause, and as a matter of 
course, the disproportions of the constituents of the 
organic elements, growth of parts, appetite, die. &c. are 
morbid results, and should be corrected if we expect to 
change or check this diathesis. Those exalted develop- 
ments of one set of organs and deficiency in others, 
from a specific stimulus, are in exact accordance with 
the laws of the economy, and the modus operandi of 
all our medicinal agents. Yet strange as it may ap- 
pear, it is nevertheless true, that the efforts of nature 
to husband life in the establishment of the increased 
nutritive process, is in accordance with the physiolo- 



66 STRUMOUS HABIT. 

gical laws of life, which is manifest from the nutritive 
process being thrown upon the white and compound 
tissues, and by which the organic elements are kept 
in harmonious proportions. So, in the wisdom of the 
arrangement, we find nature is capable of acting phy- 
siologically, and yet on the one hand promoting the 
laws of life, and on the other, the laws of death. But in 
looking at the wisdom of this apparently contradictory 
movement, we find the functions of life pleasantly and 
safely conducted, in at least one third of the afflicted, to 
the age of puberty. Again, by the movements of this 
vital arrangement, after passing this climacteric age, 
and that too, when deprived of the tissues used in per- 
fecting the growth, we find nature on the alert to 
extend the vital spark, by depositing a portion of the 
white fluids in different parts of the body, to equalize 
the organic elements, and sustain life until the deposit 
becomes solidified and enlarged. But alas, the wisdom 
and ability of nature is not by any one of those vital 
and physiological movements, able to free herself of 
the latent virus, and hence the system is still in a 
pathological state, with the tubercular deposits acting 
as irritants on new parts, establishing vascular action, 
which softens the tubercular bodies, establishes a rapid 
waste of the economy, and eventually closes the 
scene with poor mortality. This is not fancy, but 
what every observing practitioner knows to be true, 
if he relies upon the physiology of man, and the modus 
operandi of the remedial agents. And where is the 
remedial agent that in proportion to its medicinal, 
stimulating or depressing influence, is not found to be 
capable of acting physiologically on one set of organs, 
or vessels, whilst another set is brought into a patho- 



STRUMOUS HABIT. 67 

logical condition, or that state, which suspends the 
natural secretory or nutritive functions? Such a state 
may be produced by the stimulant, having invited more 
of the vital fluid to one set of organs than was com- 
patible with its functions, whilst a second set may 
have too small a supply to enable the organs to per- 
form their offices ; or, they may be suspended in their 
functions, by nervous irritations, depressions and capil- 
lary congestions, or mechanical obstructions in the 
course of the circulation. All changes from the nor- 
mal standard are liable to produce an increase of the 
functions in a part of the organs, and a diminution in 
another ; and all of those altered actions are either in 
favor of life or against it, owing to the physiological 
law of life, or the pathological law in favor of death. 
Hence we recognize the wisdom of nature in checking 
the tendency, while she is unable to free herself from 
the morbific agent ; or prevent a continuance of the 
pathological condition. On similar principles our 
remedial agents act, and for the want of a correct 
knowledge or attention to the physiological or patho- 
logical effect of medicine, much injury is done within 
the limits of the profession, and thousands of our 
species shorten their days by the use of those quack 
nostrums termed expectorants. They only irritate the 
lungs and invite a greater afflux of blood, which in- 
creases the secretory efforts of the organ, and not 
unfrequently establishes ulceration in simple catarrh, 
and prepares the lungs for the disease it professes to 
cure. For twenty years I have ceased to give expec- 
torants in tubercular disease, knowing that all such 
remedies invite the afflux of blood to the part, from 
which the expectorated matter is formed by the secre- 



68 STRUMOUS HABIT. 

tory process. Expectorants are admissible only in 
pneumonia and inflammatory diseases, but not in 
tubercular affections. 

Tubercular patients are subject to a complication of 
catarrhal pleuritic attacks, or bilious pleurisy, and 
require antimonials, ipecacuanha, opium, and mercu- 
rials sparingly, with leeching, &c. to moderate the 
febrile and inflammatory symptoms; but no stimu- 
lating expectorants, as curative agents. Febrile or 
inflammatory action is dependent upon organic dis- 
ease, excited by a specific virus, which in the early 
part of life had perpetuated in the circulating fluids, a 
disproportion between them and the organic elements 
of the blood; the excess being in the white part dur- 
ing the growth of the individual and deposition of the 
tubercular formation. After the suppurative process 
becomes established, it is obvious from the rapid 
emaciation, the tissues being liquefied, that the red 
fluids predominate; as we find that the cellular and 
adipose membranes have been thrown off by the 
waste of the system ; and is this in accordance with 
the physiological laws of life, or the pathology of the 
disease ? It has been shown that nature at all points 
exerts her vital energies to maintain a balance in the 
organic elements, and preserve the harmony of the 
entire economy, which is the bulwark of existence. 
Hence I infer, that the red blood predominates in the 
ulcerative stage, from the tissues which are liquefied 
and taken into the circulating mass to maintain the 
organic elements of the blood. In some instances 
we find a spontaneous cure after the ulcerative process 
has been fully established, and we know such results 
could not occur until the diathesis was removed. 



STRUMOUS HABIT. 69 

We have also similar instances of cure in white swell- 
ing by changes of the diathesis, after many years' dis- 
charge in some, and in others a few months. In like 
manner the lymphatic glands suppurate favorable to 
the cure of some, and unfavorable to others. This 
suppurative action, or ulcerative process, appears to be 
the last resort, or effort of nature, which cannot, under 
the circumstances, be classed as a voluntary effort from 
the history of the disease as heretofore given. But it is 
worthy of notice in a practical point of view, as we 
find that a change is brought about in the constituent 
organic elements of the fluids, which purges the system 
of the peculiar diathesis, and leaves the individual 
clear of disease. 

The suppurative process, as has been shown, is 
called into action by additional irritation, derived from 
tubercular bodies, acting as irritants, and obstructing 
the course of the blood-vessels, establishing vascular 
action, which softens or converts those organic bodies 
into pus ; notwithstanding in the process, we have 
occasionally a spontaneous cure, which very clearly 
indicates the course to be pursued after an extensive 
tubercular deposit has taken place. 

Having thus given such an outline of my views of 
strumous habit as is consistent with the limits of this 
essay, and having given the reader the opportunity of 
determining whether they are well or ill founded, I here 
recapitulate the several heads that a condensed view 
of the position may be had. 

First. Strumous habit is a predisposition, or heredi- 
tary taint derived from parents. 

Secondly. It is not the only source from which the 



70 STRUMOUS HABIT. 

disease is derived. It may be generated by other 
causes, such as eruptive disease, &c. 

Thirdly. All complexions and colors of hair are 
alike subject to the disease. 

Fourthly. The index to strumous habit will be 
found in the condition of the muscular system, which 
is always of a soft, lax character, although the child 
may have an universal plump and rudy appearance, 
from an inordinate development of the cellular and 
adipose tissues. 

Fifthly. Children that labor under strumous habit 
have a variable appetite with irregular bowels ; and 
their digestive apparatus is more frequently deranged 
by dentition. 

Sixthly. The abdomen of both children and adults 
of strumous habit has a sagged appearance, and is 
tumid in the lower portion. 

Seventhly. The lax and weak condition of the mus- 
cular system is owing to a disproportion in the organic 
elements of the fluids. The increased growth of the 
cellular and adipose tissues are dependent upon the 
same cause in childhood. 

Eighthly. The weak condition of the muscular 
fibres permits the viscera of the abdomen to gravitate 
to the pelvic cavity, and not unfrequently, the fluids to 
the most pendant part. 

Ninthly. It is necessary in the treatment of this 
disease to restore the physical, as well as the organic 
functions. 

Tenthly. To prevent, or correct the consequences 
arising from this diathesis, we must correct the pre- 
disposition, and obviate the causes which are capable 
of exciting the latent diathesis to action. 



STRUMOUS HABIT, 



71 



Eleventhly. The bowels being permitted to gravitate 
is one of the principal exciting causes of the disease, 
and to a large class of chronic diseases, is a predis- 
posing cause in some, and an exciting one in others. 

But as the object of these essays is not so much a sci- 
entific disquisition on the diseases herein enumerated, as 
a narrative of more than thirty years practical obser- 
vations made in an extensive practice in various parts 
of the western country, it will be understood that in 
making out the indications, and suggesting the means 
for the alleviation and cure of the disease, the approved 
remedial agents to meet the indications, and various 
changes, are continued in connection with the addi- 
tional remedies herein submitted. In all cases, how- 
ever, I have been governed in the application of 
remedies, by the indications of the disease, without 
bending to theories or existing opinions, and have ap- 
plied such hygienes or prophylactics as I conceived 
best adapted to the condition of the patient. But in 
this particular disease much may be gained by early 
treatment. The unnatural development of the cellular 
and adipose tissues is a delusive mark, which deceives 
the parent and prevents the unobserving of the pro- 
fession from discovering the early existence and move- 
ments of this double faced diathesis, until it is too late 
to hope for relief from remedies. Hence the necessity 
of the closest scrutiny and of correct judgment, to 
ascertain its earliest symptoms, to detect the latent 
malady and arrest its devastating influence in its un- 
suspected state. 

In this disease the intelligent physician will discover 
an unfavorable prognosis, when it is fully developed in 



72 STRUMOUS HABIT. 

the respiratory organs, or on the mesenteric glands, 
but such indications should not paralyze his efforts, 
The physiological and pathological movements of the 
economy, in procrastinating the tendency to death, 
and occasionally effecting a cure, are hopeful indica- 
tions, and must not be forgotten in the application of 
remedial agents. 

The writers of all ages having admitted that stru- 
mous habit is inherited in a majority of cases, and 
the remainder from many causes, are owing to en- 
grafted diathesis, as has been shown, whether in- 
herited or engrafted, the disproportion in the organic 
elements is the same. This being understood, the 
next great difficulty is to discover which of the 
agents of the materia medica will change the patho- 
logical condition, and place the disease under our con- 
trol. In my early practice deeming it important to 
discover if possible this desideratum, I was led, when 
the stomach was deranged, and the circulation of the 
blood determined to the lungs, to the use of emetics, 
cream of tartar and jalap, with alteratives and such 
like remedies to regulate the bowels and reduce the 
quantity of white fluids. But these agents, I found, 
were only suited to certain conditions arising from 
the virus, or accidental causes, and were too active 
to be continued for any length of time, without in- 
creasing the pathological condition of the system. 
I next tested the preparations of iron, many of 
which had a reputed property for increasing the red 
part of the fluids, and acting as a tonic and altera- 
tive; but here again, I found they only acted as 
diuretics, and so long as the effect continued, the 
patient's strength, to some extent, improved. This re- 



STRUMOUS HABIT. 73 

suit being uniform, I determined to test all the diuretic 
and diaphoretic tonics and alteratives, that seemed 
from their effect upon the system, to combine the 
greatest amount of active properties, in exalting one 
set of organs in favor of life and depressing others 
in favor of the virus. These experimental tests re- 
sulted in a preference to the constitutional agents 
which will be found at the conclusion of this essay. 
They are to be employed in connection with agents now 
in use, which are best calculated to relieve the symp- 
toms, and divert the circulation from the local seats, 
without interfering with the constitutional course pre- 
scribed for the change of the diathesis. 

Treatment, — As it has been shown that the diseases 
arising from a strumous habit derive their origin from 
an inherited or engrafted diathesis, which gives a pre- 
ponderance in favor of the white over the red fluids, 
and the tissues that derive their nutritious supply from 
them, it will be important to keep in view the indica- 
tions necessary to relieve the local seats that are likely 
to be established by the diathesis, and apply the reme- 
dial agents that are calculated to obviate the tendency 
of sucfrlocal seats, and restore the balance between the 
organic elements of the fluids, and the nutritive vessels 
that preside over the muscular system. This being 
understood, the following general indications are 
given. 

1st. To meet the first general indications, we should 
apply the remedies that would diminish the quantity 
of white fluids, and increase the red. 

2d. Restore the general tone and vigor of the 
muscular system. 

3d. Correct the functional derangement of the ali- 

7* 



74 STRUMOUS HABIT. 

mentary canal, the kidneys and skin. The remedies 
required for this class are applicable from infancy to 
adult age, except in cases where there is high inflam- 
matory action. In the more advanced or ulcerated 
stages, we must first diminish the acute or chronic 
inflammation of the mucous membrane or organs. 

4th. We must diminish the morbid excitement and 
irritability of the system. 

5th. To lessen so far as remedial agents are capable 
the determination of the circulation, from the inflamed 
structure. 

6th. As the diseases arising from strumous habit, 
depend upon the disproportions of the organic elements 
of the blood, the principles in the cure will be found 
in such remedial agents as are calculated to restore 
the loss of balance in the organic constituents. This 
must be looked upon as the desired object of the art, 
which is to be obtained bv assisting the physiological 
laws of life, through the natural emunctories of the 
economy, which are provided as outlets to the system. 
Hence exercise, bandages, diuretics, diaphoretics, 
alteratives, diet and tonics, are to be used, to meet the 
indications as they occur. For instance, if the skin 
is not healthy, restore its functions, and in like man- 
ner attend to the muscular system, kidneys, and 
digestive organs. By sustaining them, and gradually 
soliciting an exalted action by appropriate remedies ; 
first of one, and then the other, as will be indicated in 
the progress of the disease, will overcome the dia- 
thesis. The materia medica contains the adequate 
medicinal agents, but as I have been obliged in my 
clinical pursuits to form some new compounds, I will 
at the close of this essay, submit them, with their 



STRUMOUS HABIT. 75 

doses and effects, that the physician may meet the 
indications, according to the deranged functions before 
him. Believing with many of the profession, that 
specific*directions are unsafe and calculated to make 
empirics rather than practitioners, I have no hesita- 
tion in saying that the bedside is the only place to 
determine the remedies that are required to restore 
the lost harmony. Members of the same family labor- 
ing under the same disease may require different reme- 
dies, owing to the peculiarity of constitution, or loca- 
lity of the disease, though the object to be gained in 
each be the same. 

The remedies therefore that have been found best 
adapted to the first indication, are suitable suspensory 
jackets, or an abdominal supporter, to prevent the 
viscera of the abdomen from gravitating from their 
natural position, and to enable the patient to partake 
of the proper exercise in the open air. But the exercise 
should be moderate and divided between the forenoon 
and afternoon, and if not too weak, to be continued 
until perspiration is freely established. Where the in- 
valid is feeble, a moderate quantity of old rye whiskey 
and water, should be taken to brace the muscular sys- 
tem and promote perspiration, and after the exercise, 
a similar quantity to prevent the system from sinking 
too rapidly. Our ability to exercise is in proportion 
to the strength of the muscles, and as the strength 
of the system increases, the spirits should be gradually 
diminished and the exercise increased. By strictly 
persisting in this course, with a rich nutritive and 
digestible diet, the diathesis is diminished, slowly 
in some, until the system is free from the dispro- 
portions of the organic elements ; while in others 



76 STRUMOUS HABIT. 

it appears not to diminish the disproportionate growth 
between the muscular, the cellular and adipose tissues. 
But should the system fail to improve under the use of 
the whiskey, exercise and diet, medicines that act as 
diuretics, and tonics may be given. The best I have 
found in my practice is the apocynum undras ami- 
folium or dogs-bane, or apocynum cannabinum. Fifteen 
drops of a tincture prepared of these articles, given 
in a wine-glassful of the decoction of dandelion, may 
be given three times a day. The decoction should be 
boiled so as to extract the strength of the root, that 
each wine-glassful will contain at least the property 
of two drachms. Under the influence of this medicine, 
one-third of the strumous constitutions will improve, 
and one sixth will be cured, or at least, I have had 
many cases that have been relieved for twenty-six 
years without a recurrence. During this course of 
treatment, it is not unfrequent that the invalid will be 
covered with ulcers about the head, neck, and indeed 
over the whole body, with occasional cellular abscesses. 
Where the lymphatic glands suppurate, or become in- 
durated in the neck, axilla, or groin, the suppurative 
process should be promoted by emolient poultices; but 
if the poultice should fail to soften the indurated 
glands, the salt or brine mush poultice, should be ap- 
plied until there is a free discharge ; which after the 
application of the salt poultice, occurs in a week or 
fortnight. After the ulcerative action has been estab- 
lished the discharge should be kept up by the ordinary 
remedies and dressings, as recommended in surgi- 
cal works, until the glands are reduced, or the en- 
largement has subsided. But should the dressing be 
insufficient to keep open the ulcers and promote the 



STRUMOUS HABIT. 77 

discharge, the salt poultice should be resumed for a 
day or two only. This poultice should not be per- 
mitted to rest upon any more of the integuments 
than is necessary for the suppuration of the glands, as 
the salt will ulcerate the part it rests upon ; it should 
be very salt and renewed night and morning. In the use 
of this poultice, the inflammation and irritation will be 
regulated by emollient poultices and aperients. This 
must be looked upon, and considered as the desidera- 
tum in the cure or alleviation of this diathesis where 
it is seated in the lymphatic glands. But if the reme- 
dies, and the exercise as recommeded, fail to check 
or mitigate the tendency, further aid will be required. 

I have observed that where the exercise and the 
remedies recommended had failed to check or mitigate 
the tendency of the diathesis, the agents were not suffi- 
cient to maintain the integrity of the perspiratory, di- 
gestive, hepatic, and intestinal functions. In such 
constitutions the skin is most generally of a dry, 
husky, sallow hue, with a motly appearance. From 
these indications the medicines with the exercise and 
supporters, must be sufficient in their remedial effect 
to maintain the healthy action of the bowels, kidneys, 
liver, and skin ; if not, recourse must be had to two 
or three small doses of calomel — two grains night and 
morning may be given. Twelve hours after the last, 
follow it with a dose of cream of tartar and jalap, 
which will spur the biliary organs, and gradually 
bring them back to their natural action by a different 
class of remedies. 

Much caution is required in the use of mercurial 
remedies, as they increase the already weakened mus- 
cular system. To restore the action of the skin, liver, 



78 STRUMOUS HABIT. 

kidneys, and internal secretion, take from fifteen to sixty 
minums of the tincture described under the head of apo- 
cymim cannabinum. This tincture is a diuretic, aperient, 
stimulant and alterative. The dose to be extended no 
further than will maintain the bowels in a soluble state ; 
during the use of the tincture, the entire body should 
be sponged every night with whiskey. In a majority of 
cases, the tincture will restore the functions of the skin 
and internal organs, unless the lungs or mesenteric 
glands be too fully crowded with tubercular deposits. 
Where febrile excitement springs up from the use of it, 
omit it for a week or a fortnight, and give occasionally 
a dose of jalap, which is one of the best cathartics that 
can be used in this diathesis. It uniformly diminishes 
the quantity of white fluids, and where the bowels are 
constipated, or in a loaded condition, a few active 
doses combined with cream of tartar, repeated every 
third or fourth day, will remove the torpor of the 
bowels, and febrile action, that may accidentally arise 
in the early stages of the disease. In the course of 
the prescription it will be recollected that emetics, 
chalybeates, hydriodate of potassa, and sarsaparilla, 
with other remedies as the symptoms and condition of 
the organs may indicate, should be given. If catarrhal 
symptoms or congestion of the lungs are present, an 
emetic or two will give relief. When the debility of 
the muscular system is not improved by exercise, the 
tincture and chalybeates may be resorted to, and 
when the general constitution is apparently free from 
the diathesis, except indolent lymphatic enlargements, 
hydriodate of potassa, iodine, and sarsaparilla may be 
given ; but let it be observed that the various prepara- 
tions of iodine, in a majority of cases, are only admis- 



STRUMOUS HABIT. 79 

sible for a short period, and then as a stimulant, to 
dormant organs or relaxed tissues. The ultimate effect 
where long continued, is deleterious upon the mucous 
membrane. Many preparations of iodine are of great 
value in cases where the skin, eyes, and slight lympha- 
tic enlargements manifest the local seat of the disease ; 
but by a prudent and persisting continuance of the 
exercise with such constitutional remedies as will here- 
after be explained, the iodine may in some measure 
be dispensed with. In the early stage, a very large 
majority may be cured or have the virus so far sub- 
dued as to enable the patient to live three score years 
and ten, if taken in the incipient stages. 

Exercise alone is of little benefit, in this order of dis- 
ease, though it be of the most approved kind, that of 
riding on horseback. Exercise to be beneficial to the 
invalid must be selected to suit the disposition of the 
individual, so as to exercise the mind as well as the 
body. The human family is so organized as to for- 
bid a submission to arbitrary rules or directions, and 
hence the necessity in such cases for the physician 
to make himself acquainted with the means of the 
family, or the individual, before the prescription is 
given. The inclination should also be consulted, and 
the confidence of the patient secured by consulting 
as to the propriety of the course. But the exercise is 
not sufficient, no matter how well directed, to change 
the diathesis, and we have first to inquire what is 
expected from its effects upon the general system ? 

If we judge from the most approved writers, we 
are to expect from the exercise an improvement in 
the general tone of the muscles, by which the diges- 
tive apparatus would be increased, in vigor, and the 



80 STRUMOUS HABIT. 

entire economy benefited to a greater or less extent. 
If continued each day for a sufficient length of time, 
the sensible exhalation of the skin is increased, and of 
course the insensible in like proportion. The increase 
in the strength of the muscular system, is certainly a 
grand link in the chain of restoration, and the improved 
condition of the digestive organs is of equal import- 
ance as the entire organism is dependent upon this 
vital laboratory for its supplies ; but it has been shown, 
that in the strumous diathesis it is not unfrequent that 
the digestive organs with the outward appearances, 
are doing well ; while the latent disease still continues 
in the system, ready to be called into action, by the 
first irritating or debilitating cause. By the same 
writers who have judiciously prescribed the exercise, 
it will be seen, that the weak condition of the mus- 
cular system, should have admonished them to pre- 
pare their patients before commencing the exercise. 
The admitted feeble condition was, however, not suffi- 
cient, and notwithstanding the debility, the invalid is 
directed to exercise in proportion to his strength, in 
the open air, and nine out of ten are frightened in a 
very short time by the rapid increase of the symptoms 
produced from the gravitation of the bowels. Hence 
confidence is lost, the profession abandoned, and resort 
is had to the boasted nostrums of the day for the cure 
of the disease. But would this have been the case if 
the invalid had been directed to apply a suspensory 
bandage, or a supporter, to prevent the gravitation of 
the viscera of the abdomen? According to the medical 
writers, the human system receives much benefit from 
exercise ; but from my experience in strumous consti- 
tutions there is not more than one in twenty that 



STRUMOUS HABIT. 81 

escapes exhaustion from the first attempt, and as soon 
as they place themselves in a position for rest, and 
give the body a forward inclination, the axis is 
changed, and the small intestines and sigmoid flexure 
pass into the lower pelvic cavity, where they remain, 
unless restored by the recumbent posture. My residence 
in a state where the major part of the white popula- 
tion are actively engaged in tilling the soil, and where 
there exists a large slave community, has afforded 
me ample opportunities for examining, both before and 
after death, the truth of this position. 

By exercise, when guarded by bandages, suitable 
clothing, diet and medicine, and so regulated as to 
maintain the functions of the skin, kidneys and diges- 
tive organs, with a gradual solicitation of these func- 
tions, and the pulmonic exhalations, strumous diathesis 
may be removed from children, and from the adult 
when in its incipient stage. The indications in the 
more advanced stage, are, 

I. To diminish the irritability of the system, and 

the acute and chronic inflammation of the mu- 
cous membranes, and organs, and to divert the 
circulation from the inflamed parts. 

II. To prevent tubercular formation in one, and the 

ulcerative process in the other. 

III. To change the diathesis, which consists in an 
excess of white fluids, and a deficient quantity 
of the red. 

IV. To increase the crassamentum of the blood 
where hemorrhage occurs from tubercles of the 
lungs. 

The first indication may be met by leeching, cup- 
ping, ipecacuanha, Dover's powder, and counter- 



82 STRUMOUS HABIT. 

irritants. The second, by diuretics, diaphoretics, sea- 
tons or issues in the arms, if the lungs be ulcerated, 
with alteratives, tonics, and stimulants. In addition* 
resort should be had to frictions and counter-irritants, 
such as tartar emetic ointment, and to the exaltation of 
the secretory functions of a distant set of organs, with 
specific medicinal agents, that will invite the circula- 
tion to the parts. For instance, the liver and kidneys 
should be excited, if the lungs are the local seat — if the 
mucous coat of the bowels, mesenteric glands, the skin 
and kidneys — if the lymphatic glands, the exhalents of 
the bowels should be called into action. The third is 
to be met by alteratives, to sustain the digestive organs, 
as near as possible with the virus existing in the 
economy, and gradually solicit alternately and jointly, 
the functions of the skin, kidneys, lungs, and exhalents 
of the bowels. This requires the aid of all the con- 
stitutional agents, alternated in accordance with the 
symptoms which can only be made out in the sick 
room, and by the known properties of the remedial 
agents. To meet the fourth indication, table salt may 
be taken freely when the hemorrhage is profuse, and 
regularly after the first appearance for at least eigh- 
teen months. The quantity should be in proportion to 
the emergency, from two drachms to an ounce dis- 
solved in half a glass of water, and repeated until the 
hemorrhage is checked. After which the doses will be 
varied from twenty to sixty grains twice or thrice a 
day. If the mucous membranes of the stomach and 
bowels are very irritable, the doses should be small. 
I have been obliged to reduce the dose to thirty grains 
per day, and that divided into six equal parts, and 
taken every two hours. By the salt and diuretics f 



STRUMOUS HABIT. 83 

such as digitalis, the violent form of the disease may 
be checked ; but digitalis, though it acts promptly as 
a diuretic, has a deleterious effect upon the mucous 
membranes of the stomach, overbalancing its salutary 
effect, if continued for any length of time. The salt in 
small doses acts as a tonic, and will, if continued, go 
very far in diminishing the white fluids, and in increas- 
ing the red, and is one of the most potent remedies in 
the hemorrhagic form of the disease. I have tested 
this remedy in my own system for thirty years, and in 
many others with extraordinary effect. I have also 
tested it in uterine hemorrhage, and bleeding from the 
nose and gums, and have found it equally prompt in 
its action in all debilitated constitutions. The salt 
increases the crassamentum of the blood, and in large 
doses produces nausea sufficient to influence the heart 
and arteries. It is peculiarly adapted to constitutions 
that are subject to hemorrhage from any cause except 
plethora. After the strumous constitutions have been 
neglected until the morbid action has established the 
stage or local termination called tubercular consump- 
tion, it is a hopeless case, and the cures which take 
place appear more the result of accident than the effect 
of medicines. But as spontaneous cures do occur after 
the tubercular deposits become converted into pus- 
like fluid, expectorated or discharged, the physician 
should watch the movement and tendency of the virus 
and assist the efforts of nature. In such cases I have 
uniformly directed the constitutional course, combined 
with tonics, and counter-irritants that were calculated 
to divert the circulation from the local seat. I found 
the] seaton or issue in one or both arms below the 
insertion of the deltoid muscle by establishing a 



84 STRUMOUS HABIT. 

counter-drain, and by attending to the constitutional 
symptoms, retarded the progress of the disease for 
many years in some individuals, and in others a spon- 
taneous cure was effected. In the ulcerative stage, I 
found a saturated tincture of sanguinaria canadensis — 
six drops three times a day, given in a decoction of 
dandelion, regulated the action of the heart, augmented 
the secretions of the liver, and improved the entire 
system. The tincture, in the constitutions where the 
local seat terminates upon the osseous system termed 
white swelling has always a good effect. The term 
tonic in strumous diseases is not intended to apply to 
the general class of remedial agents, as found in the 
materia medica ; but only to such as are combined 
with diuretic effects. The best remedial agents in the 
treatment of this order of morbid action, are to be 
found in that class termed emetics, diuretics, diapho- 
retics, and alteratives. Some however, of each class, 
are objectionable from their effect upon the intestinal 
mucous membrane. Colchicum, digitalis, with the 
excess of the preparation of iron and iodine, may be 
resorted to when the lungs are ulcerated as adjuvants, 
but no further. Expectorants are not admissible in 
this disease ; at least such as are compounded for the 
cure of consumption, by " consumptive curers" Muci- 
laginous drinks, combined with ipecacuanha, hyoscy- 
amus, or some one of the preparations of opium, will 
be sufficient, unless the vascular action be too high 
for the controlling powers of the ipecacuanha. In 
such the antimony similarly combined will control the 
inflammatory action, and attenuate the fluids. All ex- 
pectorants, except the nauseants, anodynes and muci- 



STRUMOUS HABIT. 85 

laginous articles, must necessarily shorten the days of 
those who are deluded by their therapeutic effect. 

Having thus given the outlines of my mode of 
treatment, I subjoin the compounds, with the effects 
and appropriate doses for adults, to enable the pro- 
fession to determine their utility, and prescribe them as 
the local and constitutional symptoms indicate. 



Apocynum Cannabinum. 

Indian Hemp, 

The medicinal properties of this article are emetic, 
cathartic, and diuretic, as represented in our medi- 
cal dispensatories, but from my observation, it is also 
alterative, diaphoretic, and tonic. In my practice I 
have always used it in the form of a saturated tincture, 
and powder. The dose of the latter is from six to eight 
grains three times a day. The tincture is made as 
follows : 

Take of the root, coarsely powdered, one pound ; 
cochineal powdered, two drachms and a half; proof 
spirit, two pints ; macerate fourteen days, express and 
filter. 

The dose is from fifteen drops to a drachm 
three times a day. The best mode of regulating it 
is to observe the effect produced upon the bowels, 
which should be kept only in a soluble state when the 
object is to produce a tonic effect. As an alterative and 
diuretic, where high inflammatory action exists, the 
dose may be increased to one and a half drachms 
twice or thrice a day. 



86 STRUMOUS HABIT. 

ASCLEPIAS TUBEROSA. 

Butterfly- Weed. 

The medicinal properties are, as laid down in the 
Dispensatory, diaphoretic, and expectorant, without 
being stimulant. In large doses it is also cathartic. The 
principal properties, according to my experience, are 
diaphoretic, aperient and tonic ; as a diaphoretic, it 
should be given in decoction. One ounce of the root 
to a pint and a half of water, boiled down to one pint. 
One ounce of this decoction may be given every two 
hours until the effect is produced. The saturated 
tincture may be made in the same proportion as the 
above, and given in drachm doses three times a day, 
which promotes the secretions, and pulmonary exhala- 
tions. 

EUPATORIUM PERFOLIATUM. 

Thoroughwort. 

The medicinal properties of this article, though fully 
described in the medical Dispensatory, I use as a tonic 
and diaphoretic in strumous habit. 



Triosteum Perfoliatum. 

Fever Root. 

This article is said to be cathartic, and in large 
doses, emetic ; according to the late Professor Barton, 
diuretic. From my experience, it possesses tonic and 



STRUMOUS HABIT. 87 

diuretic properties, and in very large doses emetic and 
cathartic, either in powder or extract. The best 
mode of administering it in this class of diseases is in 
the form of a saturated tincture, which may be made 
as above, and given in doses of one drachm and a 
half, mixed in one ounce of port wine where there is 
much debility. 



Saturated Tincture of Sanguinaria Canadensis. 
Blood Root. 

Take blood-root coarsely powdered, half a pound, 
diluted alcohol two pints ; macerate ten days, express 
and filter through paper. 

This article, in the United States Dispensatory, is 
said to be "acrid, emetic, with stimulating and narcotic 
powers. In small doses it excites the stomach and 
accelerates the circulation ; more largely given, it pro- 
duces nausea, and consequently depression of the 
heart, and in full doses, vomiting. The effects of an 
over dose are violent emesis, a burning sensation in 
the stomach, tormenting thirst, faintiness, vertigo, 
dimness of vision, and alarming prostration.'' 

Such is the history of this invaluable article, which 
to my notion, has been too much neglected. During a 
practice of thirty years I have found it uniform in its 
alterative powers. In medium doses stimulant, and 
tonic in small doses ; and when given night and morn- 
ing in powder or saturated tincture, in ordinary doses, 
say two grains of the powdered root, or eight drops 
of the saturated tincture, it has a decided influence 
over the heart and arteries without producing nausea. 



88 STRUMOUS HABIT. 

In combination with the dandelion extract, or decoc- 
tion, it accelerates the secretions of the liver and 
kidneys. Given in combination with the extract of 
conium, I have found it of great advantage in chronic 
diseases of the spleen and liver, originating from stru- 
mous habit. The saturated tincture has been pre- 
scribed in connection with the fluid extracts and 
decoctions prepared by me in the treatment of struma, 
as well as in a variety of chronic diseases ; and in all, 
it has proved serviceable. The sanguinaria, like all 
heroic remedies, requires to be given in moderate 
doses and not continued too long at a time. 



Tincture Prunus Virginiana Compound. 

Wild Cherry. 

Take of the recent bark, bruised, three pounds, 
cimicifuga racemosa, powdered, one pound, diluted 
alcohol four pints ; macerate one pound of the prunus 
virginiana with one- third of the cimicifuga in a close 
displacement apparatus five days, then remove the cork 
and displace the tincture and remove the old material, 
and so pass the spirit through the two remaining por- 
tions. After it is displaced the third time, filter and add 
three drachms oil anise, and after three days, add six 
ounces of simple syrup. The dose of this tincture is 
from one to two drachms twice or thrice a day. 

In this simple tincture, if the bark be procured 
fresh each day that the spirits are placed in the appa- 
ratus for macerating, the tincture will be found to 
contain all the active principles of the prunus vir- 
giniana combined with the additional articles. This 



STRUMOUS HABIT. 89 

tincture quiets the nervous system ; promotes di- 
gestion, and increases the pulmonic exhalations; by 
combining with it a little hyoscyamus at bed time 
it will tranquilize the system and afford comfort- 
able rest. This tincture may be variously combined 
with diuretics, diaphoretics, anodynes and stronger 
alteratives and aperients. It combines as large an 
amount of the hydrocyanic acid as can well be held 
in solution. Where hectic fever in strumous habit is 
present, it has a salutary effect. By its combined 
properties it quiets the nerves and reduces the action 
of the heart; by taking it three times a day in three 
ounces of the cold infusion of fresh bark, of the prunns 
virginiana, it is highly useful in general debility and dys- 
pepsia. The quantity of the bark may appear a waste 
of material, but I have tested from one to three 
pounds, and find it contains but a small portion of the 
hydrocyanic acid, which is its principal medicinal 
property. The tincture is improved by passing the 
spirits through each parcel twice. The dried bark 
makes a very inferior article for abating the nervous 
irritation, but acts as a tonic without increasing febrile 
action. 

The compound fluid extract of the'smilex officinalis, 
or yellow sarsaparilia of the United States, is made 
as follows : 

Take of the root bruised one and a half pounds ; 
Honduras sarsaparilia, bruised, half-pound ; xanthoxy- 
lum bark of the root or small fibres, quarter pound ; 
dulcamara (bitter sweet), dried twigs, half pound; 
liquorice root, bruised, three ounces ; diluted alcohol, 
ten pints; digest twenty days, express, strain and 
filter ; evaporate the tincture in a water bath to six- 



90 STRUMOUS HABIT. 

teen fluid ounces. Then add white sugar twelve 
ounces, and when the sugar is disolved remove it from 
the fire. Dose, half a drachm three times a day. 
This fluid extract is an alterative, tonic and ape- 
rient, and by giving it in a wine-glassful of the infu- 
sion of eupatorium perfoliatum, made half an ounce to 
the pint of boiling water, when the skin is inactive, a 
free diaphoresis is induced, which will relieve any 
catarrhal attack without interrupting the constitu- 
tional course ; and where the kidneys fail in their 
functions, the extract should be given in the decoction 
of dandelion. Should the liver flag in its functions, 
six drops of the saturated tincture of sanguinaria 
canadensis should be given night and morning, in con- 
nection with the extract dandelion decoction. Where 
the heart and arteries are accelerated, the sanguinaria 
is equal to the digitalis. But if much febrile excite- 
ment prevails, half a grain of ipecacuanha every four 
hours will generally relieve the irritative fever without 
producing debility. 



ClMICIFUGA RACEMOSA. 

The Root. 

From the medical properties as given in the Dis- 
pensatory, this article is considered a mild tonic, with 
the property of stimulating the secretions, particularly 
those of the skin, kidneys and bronchial mucous mem- 
brane ; and by the late Professor Physick, as stated by 
the editor of the American Journal of Medical Sci- 
ences, it is said that ten grain doses every two hours 
will prove successful in the cure of chorea. My experi- 



STRUMOUS HABIT. 91 

ence is corroborative of the tonic and antispasmodic 
properties, as it certainly has a decided influence 
upon the nervous system in weak and irritable consti- 
tutions ; the functions of the skin and pulmonary exha- 
lations are also increased by a free use of the article. 
The dose of the powdered root as used in my practice is 
varied from ten to twenty grains twice or thrice a day. 
The powder is easily formed into pills, with all the 
solid extracts and gums so as to have its medicinal 
effects, conjointly with a great variety of prescriptions ; 
and as this is one of the valuable indigenous plants of 
the United States, I subjoin the compound fluid ex- 
tract, with further remarks. 

The compound fluid extract of cimicifuga racemosa 
is made of the root coarsely powdered, one pound, 
cistus canadensis or frost wort, one pound bruised or 
coarsely powdered; inula helenium or elecampane, the 
root coarsely powdered, one-fourth of a pound, apocy- 
num cannabinum root one-fourth of a pound coarsely 
powdered, liquorice root, bruised, three ounces, diluted 
alcohol ten pints ; digest for twenty days, express, 
strain, filter and evaporate, and complete as the pre- 
ceding fluid extract. The dose of this fluid extract is 
to be varied from a half to one fluid drachm, three times 
a day. This extract will be found to improve the tone 
of the digestive organs, and from its salutary effect 
upon the mucous membrane of the lungs and alimen- 
tary canal, the general system is improved, and 
where the functions of the liver and kidneys are im- 
paired, it should be given in the decoction of dande- 
lion of the strength and quantity as before directed. 
This extract is particularly well adapted to chronic 
bronchitis, and when given with the dandelion it 



92 STRUMOUS HABIT. 

lessens the determnation of the circulation to the 
inflamed membrane by its diuretic effects. 

All the above extracts when combined with diuretics 
and diaphoretics diminish the action of the heart, whilst 
they improve the general economy through their tonic 
and alterative powers. The compound fluid extract 
of cimicifuga should not be taken by any individual 
unless prescribed by a physician, as it is liable to so 
charge the system as to affect the head in some consti- 
tutions, yet I have not known it to have any serious 
narcotic effect. 



Phytolacca Decandria. 

Poke Root. 

The fluid extract of this root is made as follows : — 
Take of the root coarsely powdered, one pound ; 
yellow sarsaparilla coarsely powdered, one pound and 
a half; dandelion root bruised, one pound ; liquorice 
root bruised, three ounces ; diluted alcohol, eight pints 
— digest twenty days, express, strain or filter, evapo- 
rate the tincture in a water bath, to sixteen fluid ounces ; 
then add white sugar ten ounces, and when dissolved 
remove it from the fire. The dose is half a drachm 
morning and night. 

This extract is a powerful alterative, and is one of the 
best in the incipient stage of the disease; by giving it 
in the cold infusion of the prunus virginiana, one ounce 
of the fresh bark bruised to half a pint of water, will 
improve the digestive organs, and impart tone to the 
entire economy. It will, if continued too long, pro- 
duce tenderness of the gums, and soreness of the 



STRUMOUS HABIT. 93 

throat, in which event it should be discontinued for a 
week or more, and some one, of the other extracts 
substituted to keep up the constitutional effect. This 
extract combined with sixty grains of hydriodate of 
potassa and ten grains iodine, dissolved in two ounces 
of rain water, or distilled water, to twelve fluid 
ounces of the extract, is an excellent anti-syphilitic 
remedy. It is also good in rheumatism and such like 
diseases ; scrofulous eruptions as they are called, are 
speedily removed by this extract, by taking it in the 
decoction of the recent root of burdock. The decoc- 
tion should be made by boiling four ounces of the 
recent root in tw r o pints of water to half a pint. 



Fluid Extract Sarsaparilla Compound. 

Take of Honduras sarsaparilla one pound, yellow 
sarsaparilla of the United States half a pound, each 
ground or bruised, xanthoxylum fmxinum, bark of 
the root or small fibres of the root procured in the 
winter, or the bark of the small branches obtained 
in the spring or summer, one fourth of a pound 
coarsely pow r dered, Indian arrow wood, bark of the 
root, four ounces coarsely powdered — liquorice root, 
three ounces bruised, diluted alcohol, ten pints — digest 
for twenty days at a common temperature, express, 
strain, filter and evaporate the tincture in a water 
bath to sixteen fluid ounces. Then add ten ounces 
of white sugar, and as soon as the sugar is dissolved 
move it from the fire. The dose for an adult is half 
to a fluid drachm, three times a day. This fluid ex- 
tract is alterative, aperient and stimulant, and will be 
found a valuable remedy in all the forms of disease 



94 STRUMOUS HABIT. 

arising from strumous diathesis. By adding sixty 
grains of hydriodate potassa, iodine, ten grains, dis- 
solved in two fluid ounces of distilled or rain water, 
added to one pint of the extract, ulcers about the 
head, face and eyes, will be speedily relieved if the 
digestive organs are properly regulated. Two grains 
corrosive sublimate, and forty-five grains of extract 
of conium dissolved, and added to one pint, is an 
admirable anti-syphilitic remedy in many cases where 
the disease has become constitutional. In strumous 
habit, the mercury should be left out, and the extract 
conii added — a fluid drachm contains not quite half a 
grain, so that three drachms per day will be about 
one and one fourth of a grain to the day— to be in- 
creased agreeably to the judgment of the physician. I 
have increased the quantity of conii in this compound 
to three grains per day in chronic enlargements of the 
uterus, in strumous constitutions. 

This fluid extract is one of the prompt articles in 
the treatment of strumous diathesis, and will, in con- 
nection with the decoction of dandelion or eupatorium 
perfoliatum, increase the functions of the skin, liver 
and kidneys. It also, in some constitutions, acts as a 
cathartic, in which event the dose should be diminished. 



Compound Fluid Extract of Amygdalus Persica. 

Peach leaves, or the bark. 

Take of the recent bark of the small twigs or 
branches one pound bruised; aralia nudicaidis or false 
sarsaparilla, the root bruised, half a pound ; yellow 
sarsaparilla of the United States, half a pound ; me- 



STRUMOUS HABIT, 



95 



zereon, six drachms ; liquorice root, three ounces ; 
diluted alcohol, ten pints, macerate for ten days at com- 
mon temperature — then strain, express and filter — eva- 
porate the tincture in a water bath to sixteen fluid 
ounces — add white sugar eight ounces, and remove 
from the fire so soon as dissolved. This preparation is 
aperient, alterative and tonic — dose from a half to a 
fluid drachm three times a day. The advantages gained 
by this compound in the treatment of strumous chil- 
dren, is the immediate destruction of worms, and 
the change produced on the secretions, which prevents 
their formation; at the same time the child's general 
health is improved. The dose for a child, one year old, 
is from five to eight drops twice or thrice a day. The 
preparations of iodine are conveniently administered in 
this fluid extract, and it may be given in combination 
with either of the fluid extracts or tinctures, when the 
bowels are too tardy in their movements; given in 
half drachm doses with one drachm of the compound 
saturated tincture of the prunus virginiana, it will be 
found to improve the digestive organs, and abate the 
morbid sensibility which is so manifest in diseases of 
the stomach and bowels. I have, with the fluid extract 
and tincture given in combination, and the use of sup- 
porters and bandages, cured a great many cases of 
dyspepsia, without resorting to any other remedial 



agent. 



FEVER. 



Fever, from its frequent occurrence, its prevalence 
in various sections of our country, and its generally 
fatal tendency, has elicited the attention of the pro- 
fession more than any or all of the diseases to 
which the human family are subject. Its devasta- 
ting character as an epidemic throughout the world, 
has given its history and progress more than ordinary 
importance, and engaged in its treatment the talent 
of the profession in every age. In no part of medi- 
cal science has so much laborious research been ex- 
pended, nor has the subject escaped the controversial 
difficulties that usually prevail in relation to causes. 
And as it still remains a matter of doubt with the 
systematic writers, what part of the human system, 
or particular vessel is first impressed by the morbific 
agent, I shall endeavor to show in the present essay, 
that the first impression is made upon the capillary 
vessels and nerves, in their terminating extremities, on 
the two tegumentary surfaces and organs, at their 
connection with the secerning arteries and secretory 
vessels. And when reference is made to the capillary 
vessels and nerves, I wish it understood that the con- 
nections are included. 



FEVER, 97 

But as there has been, and still exists, a diversity of 
opinion in relation to the first local impression made 
upon the system, it will be necessary, in establishing 
my position, to examine the natural emunctories that 
have been wisely established as outlets to guard and 
protect the system against the retention of effete 
matter in the circulating fluids. By these outlets, we 
find nature, under the influence of an inherent power, 
when the system is in the full enjoyment of health, 
throwing off every thing that is foreign to the laws of 
life ; while in fever those excretory outlets are arrested 
or perverted in their functions, and as the first im- 
pression made upon the system by any morbid agent, 
is discoverable through the secretory and excretory 
organs, a cursory view of their offices, and the two 
systems that are liable to derangement, will be neces- 
sary for a clear understanding of the subject. 

The body being covered with a tegumentary sub- 
stance called the skin, through the pores of which, the 
sensible and insensible transpiration pass, it will be 
seen that in a majority of attacks, the functions of 
those emunctories are, to a greater or less extent, sus- 
pended or morbidly exalted. This fact, if there were 
no other, affords at least presumptive evidence that the 
first seat of the disease will be found upon their ex- 
tremities. But the anatomy of the tegumentary sys- 
tem demonstrates the final termination of the nerves 
and capillary vessels, with the branches of the arte- 
ries, which exhibit the connection of the secretory 
follicles, that separates from the fluids, the sensible 
or insensible exhalations. When examined by a mi- 
croscope, it appears as though these emunctories 
are composed of the extremes of the nervous and 



98 FEVER. 

circulating systems, and that in their ramifications 
their functions are dependent upon their healthy con- 
dition. The internal tegumentary system is the mu- 
cous membrane, lining the internal organs, and on their 
surface, we find the same arrangement of the two 
systems, in their terminations, and in a majority of 
cases, in the initial stages of fever the functions are 
alike deranged. The lungs having similar offices and 
endowments, are observed to suffer in like manner, 
and indeed, when we confine ourselves to close ob- 
servation, the same may be said of the functions 
of the liver, the kidneys, and of all the secretory 
organs. From their arrangements, and from what 
we observe in health, and in disease, it is a fair 
inference that the changes produced by morbific 
agents, are first upon these two systems. From some 
causes the internal nerves and capillaries receive 
the shock, and from others, the external extremes 
become the subjects of the impression. Conse- 
quently it is evident that the two systems are the 
first deranged. This being uniformly the case, it 
is of but little importance in the cure, whether the 
morbific agent be heat, cold, or marsh malaria. But 
to say, that the nervous system is the first in fault, in 
all the forms of fever, would be absurd, and the same 
remark may be applied to the charges against the 
circulating system. 

The mistaken notions of the humoralists and their 
antagonists, in my opinion, derive their origin from 
a misapprehension of the dependencies of the nervous 
system, and the vital circulating fluid in their inti- 
mate connexions. The brain with all the other 
parts of the system, is formed and sustained from 



FEVER. 99 

this vital fluid, which is declared to be the "life 
of the animal creation ;" and from the facts observed 
in the organization of man, it is already manifest, 
from the different degrees of sensibility and irrita- 
bility in the tissues. It is true, the nervous sys- 
tem possesses a greater degree of sensibility, but it 
must not be inferred, that the balance of the subordi- 
nate systems is wholly dependent upon the nerves 
for their sensibility or susceptibility. Such an in- 
ference would leave these systems without the ca- 
pacity to act, or to be acted upon, and would assuredly 
destroy the principles of life contained in the constitu- 
ent elements of the blood, which constituent elements 
gives to each tissue or organ the peculiar property for 
the purpose of endowing the parts with the energy 
requisite to the performance of their functions. 

For the purpose, therefore, of contrasting the ac- 
knowledged causes and effects, we will examine some 
of the more prominent, that act deleteriously upon the 
human system. The first are recrementitious sub- 
stances retained in the circulating fluids — such as 
checked perspiration, bile, and uric acid. These 
recrementitious fluids, when retained in the circula- 
tion, frequently give rise to disease, by establishing 
irritation. Checked perspiration is also most frequently 
acknowledged to be a secondary consequence ; so also 
is bile and uric acid. But the influence of such causes 
is calculated to establish irritation and vascular action; 
and checked perspiration not unfrequently deranges 
the functions of the kidneys by the vicarious action 
induced by these organs which produces exhaustion. 
The second cause to which the writers refer is 
irritation produced by indigestible substances, or by 



100 FEVER. 

worms, &c. generated within the body. The third 
cause is attributed to deleterious substances floating in 
the air, or the variable condition of the atmosphere ; 
such as miasmata, noxious gases, heat, cold, electricity, 
humidity, and contagious or mechanical causes. That 
the above causes are calculated to produce disease, no 
one doubts ; but are there not many reasons for believ- 
ing that an excess of these causes is harmless, unless 
too long continued in action, or when the system has 
been previously weakened by antecedent causes. In 
health we find the human system is capable of resisting 
heat and cold, in a wonderful degree. The fire-king, at 
a temperature sufficient to roast a beefsteak, is enabled 
to withstand the heat without apparent injury, and 
mankind enabled to approach the other extreme, and 
brave the cold of the frigid zone, where mercury is 
frozen, without injurious consequences. But if the 
system had been previously debilitated, either of the 
above causes would have established morbid action. 
The effect of cold or heat, too long continued, is well 
understood by the profession ; and in their extremes, 
or sudden vicissitudes, is admitted as a fruitful pre- 
disposing cause of fever in some, and in others, an 
exciting one. In many of the other admitted causes, 
the constituents are not understood, nor is the chan- 
nel known by which they enter, although it is supposed 
that it is by inhalation of animalculi or by being incor- 
porated with the saliva, and taken into the stomach. 
Either of which must make a direct impression, to 
establish morbid action. If this be the case, is it not 
probable that many of these agents are condensed 
upon the cutaneous surface, and make a direct impres- 
sion upon the nerves and capillary vessels through the 



FEVER. 101 

external absorbents ? From what I have observed 
in marshy districts, I believe those agents gain admit- 
tance through inhalation, as well as by absorption, 
both externally and internal!} 7- , which is the popular 
opinion of the medical world ; but I do not believe it 
is necessary for the morbific agent to become incor- 
porated in the circulating fluids, and thereby change 
the constituents of the blood before the poison is capa- 
ble of establishing morbid action. Nor is it consistent 
with the physiological laws observable in the move- 
ments of the economy; for on being impressed with a 
medicinal agent, we find the vital action making an ef- 
fort to expel the offending cause by the outlets provided 
for that purpose ; and through these natural outlets, 
deleterious agents are eliminated and thrown ofT from 
the system in such a hurried manner, that it is impossi- 
ble that they should have been conveyed into the cir- 
culating mass, and passed through the heart before 
morbid vascular action was established. 

To admit in all instances the incorporation of 
such materials with the blood, would be presuming 
that nature had not been provided for in the way of 
protection and defence. That many articles are ab- 
sorbed, and conveyed into the fluids cannot be doubt- 
ed ; but is it not reasonable to suppose that the vari- 
ous deleterious agents inhaled and absorbed, are only 
permitted to enter that part of the circulating system 
which conveys the limpid or white fluid ? as those 
capillary vessels appear to be possessed of an inherent 
power to resist the entrance of any material that is 
incompatible with the well being of the economy, 
until the vital forces are enfeebled or overcome by the 
long continued application of morbific agents, or some 



102 FEVER. 

violent cause. After which the entire circulating fluid 
becomes contaminated by the virus which has entered 
the system. Hence morbid vascular action is fre- 
quently established, giving rise to fever, without the 
entrance of the morbific agent into the red part of the 
circulating fluid ; as we see that the force of some of 
the noxious gases and poisons is sufficient to destroy 
life, when brought in contact with the respiratory 
mucous membrane, or any part of the vascular system. 
In many cases the effect is too sudden to admit of the 
belief of its absorption. Yet many of these deleterious 
agents, when absorbed in a diluted form, are com- 
pletely under the control of the vital forces of the sys- 
tem. In some marshy districts, the miasm is so 
abundant as to derange the capillary vessels and 
nerves, and in some constitutions, to establish fever 
of an intermittent or remittent type, in a few days : 
whilst in others, the effect of the malaria is success- 
fully resisted, and thrown off by the vital action of the 
system, notwithstanding the constitution is enfeebled 
by the continued application of the miasmata. In such 
cases, notwithstanding the efforts of the vital power of 
the system, the aspect of the countenance gradually 
assumes a sallow hue, until in some, the capillary ves- 
sels and nerves are so far overcome, that dropsy is 
the result ; whilst in others, in a more southern lati- 
tude, by the increase of the malaria, and the changes 
in temperature, we have those violent attacks of yel- 
low and congestive fevers. As it has been shown that 
the capillary vessels and nervous terminations are so 
intimately connected, it will be seen that whatever 
deranges the one, will simultaneously derange the 
other. This fact is abundantly exemplified in cases 



FEVER. 103 

of fright, or cold water suddenly douched upon the 
lower extremities; each acting upon the bowels through 
contiguous sympathies ; and also, in abrasions of the 
surface produced by the explosion of steam, from the 
shock of which we find symptoms of compression 
of the brain. Hence I infer, that in proportion 
as the qualities of the poison are obnoxious to 
those sentinels of life posted internally and exter- 
nally, so is the shock to the system, inducing the 
overthrow of the functions of the entire economy. 
These terminating extremes of the nerves and 
capillaries of the circulating systems, may be properly 
denominated sentinels, to warn us of the gathering 
clouds of disease, which are first manifested in the 
change produced upon them ; and from their angry 
appearance, we are induced to furl our sails and pre- 
pare for the tempest that is fast approaching. But 
these are not the only important services of these little 
sentinels. The evidence of returning health, the 
effect of the remedial agents, their assistance in eject- 
ing from the system the offending cause, are among 
the objects that render them worthy the closest atten- 
tion of the profession. If we examine the action of 
the economy under the influence of tartar emetic, we 
find that as soon as the agent is brought in contact 
with these guardian vessels, the physiological laws of 
the parts are increased by the stimulant applied to the 
vessels and nerves, which enables nature to free herself, 
either by ejecting from the stomach, or hurrying 
through the alimentary canal, the cause of the difficulty. 
This speedy response of nature will not admit of the 
belief in the absorption of the antimony into the 
general circulation before its effect is produced, but 






104 FEVER. 

by the impression it makes upon those vessels, estab- 
lishes exalted action, and thereby frees the system 
from the offending cause : so it may be safely inferred 
that some morbific agents are too powerful in their 
action to admit of absorption ; but perhaps if diluted, 
or of a less offensive quality, they may be absorbed to 
the extent as before stated, and when thus far taken 
into the circulation, may establish fever from irrita- 
tion or congestion. 

"Any cause," says Professor Wood, "capable of 
inducing irritation in any considerable number of the 
organs, or over any considerable portion of the body, 
either by direct impression or by the reaction which 
follows depression, or by the super-excitement in cer- 
tain parts resulting from depression in others, may 
occasion universal derangement, and consequently 
fever." Professor Pberle says, " The causes of fever 
are generally divided by pathologists into tivo varie- 
ties, the predisposing and the exciting. They are all 
those external and internal causes which tend to lessen 
the power of vital resistance to the influence of morbid 
agents. The latter are those causes which excite 
actual disease by the deleterious or irritating impres- 
sions which they make on the animal system. There 
exists, however, no absolute difference in the nature 
or character of these two varieties of morbific causes. 
The same agent or circumstances may manifest its 
influence on the animal economy either as a predis- 
posing or exciting cause of fever, according to the 
degree of intensity with which it acts, or the previous 
condition of the system" 

Hence it is admitted that in proportion to the force 
of the cause applied to the system, so is the response 



FEVER. 105 

either for weal or for woe ; and we find that it is the 
received opinion that any cause predisposing in one, 
may be an exciting cause to morbid action in another. 
Of most of the causes assigned by the writers, we know 
but little except from the localities where the malaria 
is found to prevail. We suppose them a deleterious 
something conveyed in the atmosphere, and generated 
by the influence of heat and moisture upon animal 
and vegetable matter. But it has been admitted 
that a cause with sufficient force to excite a morbid 
action by direct application or absorption, has, in like 
manner, the power to impair the animal functions, and 
to predispose one and excite another, and vice versa. 
This being clear, it will be seen that the tendency 
of the viscera and fluids to gravitate, with the altered 
respiratory movements, are fruitful predisposing and 
exciting causes of febrile action ; hence the attacks 
of fever do not all commence with diminished secre- 
tion of the skin and alimentary canal, though the 
cause may be the same ; which is owing to the inten- 
sity of the cause, and the amount of irritation or 
congestion of the capillary vessels, as was manifest 
in the two orders of attack of that frightful malady, 
the cholera. The force of the first was expended 
upon the extremes of the capillary vessels and nerves. 
In the second, the force was thrown upon the brain, 
which weakened the action of the heart, and produced 
semi-stagnation in the capillary vessels. In the 
former, the nervous twitchings and spasmodic cramps, 
with profuse perspiration, were present from the com- 
mencement to the close : in the latter, we had also 
profuse perspiration, or an effusion upon the external 
skin and internal mucous membranes, frequently 



106 FEVER. 

terminating fatally, without spasms. In some cases, 
both sets of symptoms appeared to be moving con- 
jointly. So I infer, in many cases of fever, owing to 
the deranged condition of the nerves and engorged 
capillary vessels, that the irritation produces an ex- 
alted action in some cases, constituting diarrhoea; 
and in others, a suppression of the secretions, which 
not unfrequently establishes inflammation in the sequel 
of the disease. 

Diarrhoea in fever is not unfrequently an effort of 
nature to free herself from the effects of the offend- 
ing cause, and should be carefully watched in its 
tendency, and rarely checked unless the parts indicate 
high irritation, or tenderness and pain upon pressure. 
By imprudently checking diarrhoea, produced from a 
simple catarrh, it may be changed into gastroenteri- 
tis, or increase morbid vascular action, which often 
terminates in inflammation. The characteristics of 
fever are evidently dependent upon the change pro- 
duced in the capillary vessels and nerves that are 
essentially and primarily disordered. The first mani- 
festation is suppressed or exalted action of the secre- 
tory vessels that are dependent upon the extreme 
terminations of the capillaries. In like manner, the 
first mark of convalescence is manifested in the ter- 
minating branches of the two tegumentary systems 
by the change in the secretions. But whether the 
nerves are the first or the second link in the chain of 
morbid action, it has not been ascertained; and it 
would be of little consequence, in a practical point, if 
it were; as the relations of the two systems are so 
blended, that whatever disturbs the extremes of one, 
deranges the other; and, in like manner, whatever 



FEVER, 



107 



changes the quality of the blood, impairs the brain in 
its healthful functions, and entails a similar depression 
or exalted action upon the heart and arteries. So it 
seems that the extremes of these two systems and 
centres reciprocate in health and in disease. 

These systems are, therefore, the seat of primary 
irritation, whether it be from debility or congestion, 
from which arises morbid vascular action. Hence 
the opinion of some of the writers, that fever is a 
universal malady ; but it is obvious that the entire 
organism could not be in a state of disease ; yet the 
functions may be more or less deranged through the 
influence of the morbid vascular action established 
from the derangement in the extremes or centres. 
The causes, therefore, whether chemical or mechani- 
cal, are equally liable to establish fever, and, it seems 
to me, from the admitted facts that one of the primary 
causes has been overlooked thus far. 

In the laborious research after causes, the liability 
of the viscera of the abdomen and the fluids to gravi- 
tate, with their influence upon the respiratory move- 
ments, upon the blood and upon the general system, 
have been misapprehended by the profession. The 
anatomy of the organs, and of the surrounding pari- 
etes which are endowed by nature with a capacity to 
perform certain mechanical functions, clearly demon- 
strates their importance, and, if we look at the liability 
to local irritation upon the root of the mesentery, 
established by gravitation, we cannot but ask, what 
cause is better calculated to predispose or excite fever 
than the displacement of these organs ? Consequently, 
the direct cause of febrile disease, with a large class 



108 FEVER. 

of the diseases to which we are subject, may be traced 
to such displacement. 

In the illustration of this position, we will suppose 
a case where the individual, by too long standing, 
becomes fatigued, the muscular system exhausted, and 
the small intestines having lost their natural support, 
gravitate to the true pelvic cavity; now what part is put 
upon the stretch ? Is it not the root of the mesentery? 
and is not this part abundantly supplied with blood- 
vessels, nerves, glands and secretory vessels ? What 
cause, then, is better calculated to establish a morbid, 
vascular excitement in the capillary system and nerves? 
Again, if the first link in the chain of morbid action, 
is discovered in the nerves, as contended for by some, 
have we not an irritating impression ready to be con- 
veyed sympathetically to the entire system from a 
primary focus of irritation ? And as it is known that 
the nervous and vascular systems are so immediately 
connected in every part of the body, where these two 
systems are brought into a morbid condition — as they 
manifestly must be — by the displaced condition of the 
abdominal viscera, what is better calculated to pro- 
duce fever than such displacement and weight upon the 
mesenteric blood-vessels and nerves? It is evident, 
then, from the symptoms and character of the dis- 
ease, that fevers depend upon a morbid action, com- 
mencing in the capillary vessels and terminating ex- 
tremities of the nerves, or at their centres, giving rise 
to an accelerated action of the heart and arteries. Can 
it then be doubted that the irritation is produced from 
the weight, so far at least as the capillary system and 
nerves are concerned, and that the focal point from 
which the morbid vascular action is established in func- 



FEVER. 109 

tional and inflammatory fevers, is the consequence of 
this deranged condition ? Look at the mental and 
muscular languor — the pains in the loins and lower 
extremities — the morbid sensibility to low temperature 
— the irritableness of the system, and the desponding 
weakness of the intellectual powers, so universal in 
febrile disease ; and ask, is not this unequivocal evi- 
dence of the prevailing derangement of the capillary 
vessels and nerves of the abdomen? Furthermore, 
look at the influence of the depressed condition of the 
abdominal contents upon the action of the diaphragm, 
with the loss of power in the muscles subservient to 
respiration, and the effects produced upon the blood, 
which leaves a superabundance of carbonic acid, that 
is carried to the brain, and produces the train of dis- 
eases so fully described by systematic writers from a 
weakened action of the heart. Then contemplate the 
effect of the black blood upon the brain and its influ- 
ence upon the heart, and ask if it is not more than 
probable, that the cause of fever is connected with 
local irritation at the root of the mesentery, and with 
the obstructed blood-vessels, and the consequent con- 
gestion of the capillaries from obstruction, and the 
tendency of the fluids to gravitate ? 

From the history of the causes of febrile disease 
and their effect upon the animal economy, with the 
power of the organs to resist the surrounding causes 
so long as the general harmony is preserved; and with 
the symptoms of diminished or increased action of the 
exhalents and secretory organs which terminate upon 
the internal and external, surface, it is evident that the 
febrile agents uniformly derange the functions of the 
two systems by establishing an accelerated morbid 

10* 



110 FEVER. 

action, or a diminished action, amounting to the same 
morbid results. In the former, the disease is called 
into action by an agent of sufficient power to derange 
the action of the two systems, giving rise to violent 
reaction, frequently of a malignant character. In the 
latter order of attacks, the system is exhausted in 
struggling with a distinct cause, or fixed point of irri- 
tation, until vital resistance is overcome, and morbid 
action established — constituting the grade of fever, 
called typhus, or typhoid as it is observed in the initial 
state. In the premonitory stages, we have various 
symptoms, such as loss of appetite, a furred or smooth 
tongue, disturbed sleep, with a harsh dry skin, irregu- 
lar bowels, with lassitude, pains in the bones and ex- 
tremities, slight headache, feelings of heat and cold, 
with many anomalous symptoms. By examining the 
symptoms as presented by the patient, it will be found, 
that the altered condition of the secretory system, with 
the morbid sensibilities that are manifest, and the de- 
rangement of the digestive organs, heart and arteries, 
have been produced from an impression made upon 
the vascular or nervous system ; whilst in some, per- 
haps from the same cause, the nervous symptoms take 
the lead of vascular action, and in others, the two sys- 
tems are simultaneously deranged ; which brings on 
nervous and vascular action conjointly ; thus making 
the compound order of fever referred to, by the writers. 
But of the symptoms referred to, no one is so uniform 
as the diminished or exalted actions observable in the 
emunctories, which establishes the fact that the two 
systems, at their extremes or centres, are invariably the 
first deranged, and the first to show T the returning signs 
of health. By these convictions my practice for twenty 



FEVER. Ill 

years has been governed, and has resulted in treating 
almost every grade of fever with more than usual suc- 
cess. After a conviction of the truth of the theory, my 
practice was simplified from the diagnosis being easily 
made out by the altered condition of the secretions of 
the two tegumentary systems, which freed me from 
the hap-hazard practice so frequently met with. To be 
skilled in diagnosis requires close and persevering ob- 
servation, aided by a correct knowledge of anatomy, 
physiology, and the symptoms arising from the patho- 
logical condition of the organism, taken in connection 
with the age, temperament, climate, habits, hereditary 
predisposition, and character of the predisposing or 
exciting cause. 

Having thus given a brief outline, of cause and effect, 
I now proceed to the doctrines in relation to the cha- 
racter of febrile disease. 

I. Fever is a disease arising from a general derange- 
ment of the secretory and nervous functions, 
produced by local impressions made upon the 
circulating and nervous systems, which establish 
morbid vascular action. 

II. The first part impressed by the febrile agent, is 
that of the capillaries in some, and the nerves 
in others, or the two conjointly, either of which 
affect the other simultaneously. 

III. The morbid vascular action may be established 

by a depressed or accelerated movement of the 
two systems, from direct irritation applied either 
chemically or mechanically. 

IV. The morbific causes act upon the two extremes 

or centres through the external or internal sur- 



112 FEVER. 

face, and are conveyed to the entire system by 
a morbid molecular action, which extends to the 
entire system, through the capillary vessels, or 
sympathetically by the nerves. 
V. The remote and exciting cause of fever is liable to 
produce congestion, irritation or inflammation. 

VI. Loss of balance between the capillary termina- 
tions upon the two tegumentary systems, by 
local determinations of the blood, is one of the 
strongest characteristics of fever, which is 
manifest in the initial stages by the altered 
functions manifested by chilly sensations and 
changes in the secretions. 

VII. Morbific agents are not permitted to enter the 
general circulating mass of the fluids until the 
vital force is overcome, further than the vessels 
that convey the limpid fluid, and they are fre- 
quently rejected by nature at one of the provi- 
sional outlets. 

Having thus given a summary of the observations 
collected from medical authors, clinical pursuits, and 
post-mortem examinations, in relation to the causes 
and effects of febrile disease, with my convictions as 
to the part of the system first impressed, and the uni- 
versal symptom, observable in all, of the altered con- 
dition of the secretions of the two tegumentary sys- 
tems, I propose some further remarks on the causes 
and effects of intermittent, remittent, typhus, typhoid 
and exanthematous fevers, in illustration of my views 
in relation to their treatment. 

The intermittent paroxysm that occurs every day 
or every other day, generally yields to the treatment 



FEVER. 



113 



that is calculated to maintain the balance of the capil- 
lary vessels of the internal and external tegumentary 
systems ; — we find the paroxysms are depending upon 
the periodical congestion of the internal, and a defi- 
ciency of the external capillary vessels — until the 
febrile vascular action restores the balance in the two 
surfaces, and enables the system to free itself by means 
of the secretions. To the remedies employed by the 
profession, this form of the disease generally yields in 
three or four days, and not unfrequently in less time if 
the patient attend to his diet, and wear flannel next to 
the skin. In the mild form of bilious remitting fever, 
the symptoms and treatment are very much the same 
as intermittent. But as the remittent type, in marshy 
districts, assumes a formidable character, it requires 
a treatment corresponding to its violence, and per- 
haps there is no form of fever so various in relation 
to its grade, or danger in different districts or lati- 
tudes, as the remittent type. This and its fellow, the 
intermittent type, are dependent upon like causes, and 
differ in proportion to the irritability of the system, 
local seat, and determination of the blood upon the 
internal organs, with the complications of inflamma- 
tion and congestion. If the attack be sudden or vehe- 
ment, it is alike dangerous in its progress. Owing to 
its morbid influence, the local seats of remittent fever 
are more various, and the organs of the three cavities 
are subject to its influence ; but generally those of the 
abdomen, the liver, and alimentary canal, are found to 
be most subject to its attack. The causes are uni- 
formry referred to miasmata, and their identity is evi- 
dent from the fact that intermittent becomes remit- 
tent, and vice versa ; all writers speak of either as a 



114 FEVER. 

mild form of febrile disease, and readily controlled by 
appropriate remedies. But notwithstanding the suc- 
cess attending the best directed course, is it not pro- 
bable, from the many failures in the treatment of the 
violent forms, that there is a misapprehension as to 
their causes and effects? If not, why should the skill 
of the physician, and their remedial agents fail in the 
cure ? The various departures from health in a true 
intermittent, are called the cold, the hot, and the 
sweating stages ; these three stages are characteristic 
of the disease, and are the effects produced by the 
cause or causes. From the symptoms in the cold 
stage, it is manifest that the internal capillary vessels 
are congested, whilst the external are left with a pro- 
portionate deficiency, which is obvious from the cold, 
pale and contracted condition of the surface. Then, 
is not this chill, &c. the consequence of the want of 
balance between the internal and external capillaries ? 
and the change produced upon the nerves externally, 
the consequence of a deficiency in the vital fluid, and 
upon the nerves internally, of a superabundance ? 
The functions on the one hand being diminished while 
on the other they are morbidly exalted. Is not this 
view in accordance with the anatomical arrangement 
of the two tegumentary systems — with the capillary 
vessels and nerves terminating upon the internal and 
external tunic, and with their reciprocal and physio- 
logical functions ? In all diseases we find irritation, 
congestion, or inflammation, in proportion to the loss 
of balance in the two surfaces, producing a chill. The 
approach is first discoverable at the extremities, by 
the blue appearance under the roots of the nails, which 
is soon followed by yawning and stretching, with a 



FEVER. 115 

sensation of cold, alternating with flushes of heat, 
until the cold becomes predominant throughout the 
system, After which a spasmodic action prevails until 
the reaction gradually forces the heat from the centre 
to the surface ; and after the occurrence of the hot 
and cold stages, the two capillary surfaces are balanced, 
the secretion internally and externally augmented, 
leaving the patient for twenty-four or thirty-six hours, 
apparently without disease. Thus it is evident that 
the chill is the consequence of periodical congestion, 
and also the hot and sweating stages, which are an 
effort of nature to restore the loss of balance between 
the surfaces, and free herself from the irritating cause. 
From the symptoms attending these two diseases 
it is clear that the remittent and intermittent forms 
of fever differ in the congestion of their capillary sur- 
faces. — In simple intermittent, the periodical con- 
gestion is upon the capillaries of the liver, stomach, 
and bowels; in the remittent form, of a vehement 
character, the congestion from the first chill, is to 
a greater or less extent, located in the capillary 
vessels throughout the system ; tho internal organs 
of the abdomen being the primary point, the cuta- 
neous capillaries the second, the lungs the third, and 
the brain the fourth : but in the winter season the 
lungs are frequently the primary point, in some of the 
winter epidemics. This fact, from examination before 
and after death, was discovered by Dr. Martin and 
myself in 1821. The left lobe of the lungs was found 
to be so fully congested as to give the entire organ a 
dark grumous appearance. The epidemic that then 
prevailed was so violent in its character as to extin- 
guish life in six, twelve, and twenty-four hours, and in 



116 FEVER. 

many families, induced the belief that poison had been 
secretly administered. Under these impressions the 
examinations were made, and the true character of the 
disease discovered. In the endemic of 1823, the or- 
gans of the abdomen were the seat of congestion. 
In the summers of 1838 and '39, the liver was the or- 
gan primarily congested ; in 1847, the congestion was 
on the bowels and liver, as was ascertained by Dr. 
Walker and myself. These cases demonstrated that 
inflammation, in some, existed in the small intestines 
and stomach ; in others, on the large intestines ; and 
occasionally, on the liver and duodenum. This epi- 
demic was treated by many for typhoid fever, and, of 
course, to the prejudice of the afflicted. Its character, 
however, owing to the irregular congestions and ter- 
minations, established it as a remittent fever in an 
aggravated form. In some, the initial stage of the 
inflammation induced the treatment for typhoid or 
typhus fever; in others, where the congestion was 
nearly equal upon the tegumentary systems, for con- 
tinued fever. The nervous symptoms in this fever 
are in proportion to the local inflammation of the in- 
testines. If the inflammation be on the lower third 
of the ileum, the symptoms will be found as described 
by writers on typhoid fever. If on the jejunum, the 
symptoms are as found under the head of typhus ; and 
when on the duodenum, they come under the order of 
yellow, or a high grade of remittent fever, as in these 
forms the stomach and liver are more or less affected. 
In addition to what has been stated on the causes of 
intermittent and remittent fevers, in their epidemic or 
endemic forms, produced from malaria, there are a va- 
riety of other causes; such as worms in children, irri- 



FEVER. 117 

tating substances lodged in the bowels, the depressed 
condition of the abdominal viscera, gravitation of the 
fluids, and whatever may cause sufficient irritation to 
destroy the balance of the circulation in the capillary 
vessels and derange the nervous system. But the re- 
mittent fevers produced from the latter causes are less 
dangerous than those from malaria. — In all forms, be 
the cause what it may, the impression is made on the 
two surfaces at those extremes which determine the 
consequence upon the viscera of the abdomen, and 
especially upon the mucous coat of the alimentary 
canal and liver ; and by the reciprocal action between 
the internal and external surfaces, their functions are 
deranged, producing the vascular action by which the 
entire functions of the economy are alike disturbed. 

The Eruptive contagious fevers of the order of ex- 
anthemata, are of two distinctive forms, which in the 
valuable work of Dr. Eberle are properly set forth. 
He says, " The two distinctive forms may be divided 
into two varieties, viz. — 1st, Those which consist of a 
palpable matter or virus ; and, 2d, Those which con- 
sist of an imperceptible effluvium. The chronic con- 
tagious maladies are propagated exclusively by a pal- 
pable virus, and consequently always by actual contact. 
Those acute contagious diseases which are not at- 
tended by a specific local affection, or an exanthema, 
are, on the other hand, exclusively propagated by a 
morbific contagious effluvium, and, by consequence, 
solely through the medium of the atmosphere. Those 
acute diseases which are essentially connected with a 
specific local affection, or an exanthema, are commu- 
nicated both by a palpable virus and by an impercepti- 

11 



118 FEVER. 

b!e effluvium, and consequently both by actual contact 
and through the medium of the atmosphere. 

" We perceive therefore, that of the extremes of a 
purely local and purely general malady, there is on the 
one hand communication of the disease solely by a 
palpable matter; and on the other effluvia only, and 
that where the local and the general affections meet 
in the same disease, as essential concomitants (in 
the exanthemata) the two modes of propagation, also 
obtain." But he observes that, " in reality an actual 
contact must necessarily always occur between the 
contagion and the individual before it can possibly pro- 
duce disease, whether the contagion be a palpable 
matter or an imperceptible miasm. The only material 
difference consists in the mode in which this contact 
is effected. 

" One of the most remarkable peculiarities of conta- 
gious diseases is their inherent and undeviating ten- 
dency to preserve their essential individuality, under 
whatever circumstances of age, sex, constitution, tem- 
perament, modes of living, climate, and place they may 
occur. Thus, the smallpox of the present day differs in 
no essential circumstance from that of the time of its 
discovery. — The laws of the acute contagious diseases 
differ entirely from those which govern the rise, pro- 
gress, and declension of the chronic contagious affec- 
tions. The former observes the utmost regularity in 
all these respects. The rise, advancement, and decline, 
in short, the whole series of essential phenomena, are 
governed by laws as steadfast as those which regulate 
the motions of the planets. The latter class of diseases, 
on the contrary, are extremely irregular in their course, 



FEVER. 119 

having no definite period of duration, established order, 
and duration of the successive phenomena of their 
course." 

Having thus established the character of these con- 
tagious diseases, I next proceed with the cause and 
effect, and the specific seat of the acute form, as set 
forth in the quotation. By a reference to any of the 
authors on smallpox, it will be found from the symp- 
toms, that the capillary vessels and nerves of the two 
tegumentary systems are the surfaces upon which 
these exanthematous diseases are seated ; and we find 
also that the symptoms correspond with those of fever 
of the remittent and continued type similarly located. 
Hence the sensations of the patient are, lassitude, 
aching pains in the back and extremities, with slight 
creeping chills, flushes of heat, pain in the head, nausea, 
thirst, and tenderness and pain in the epigastrium; 
and after the heat is equalized, the skin becomes 
dry, the tongue white, and in short, all the secretions 
are suppressed to a greater or less extent ; till, by the 
efforts of nature to restore the loss of balance (which 
is generally from three to four days) the secretions, to 
a certain extent, are re-established, and the eruption 
makes its appearance. During this stage, and after the 
appearance of the eruption upon the head and face, the 
patient is drowsy, and sometimes comatose. The erup- 
tion progresses from the head to the body and extremi- 
ties. As soon as it covers the surface the eruptive 
fever remits in proportion to the extent of the erup- 
tion. If distinct, the fever intermits; but if confluent, 
the intermission is not so decided ; about the sixth or 
eighth day, as suppuration advances, a slight sensation 
of chill is complained of, with an increase of fever, and 



120 FEVER. 

the head and face begin to swell, which again subsides 
in two or three days; this symptom extends slightly 
over the body, and largely over the extremities. During 
the progress of the suppurative process, the internal 
tegumentary system labors to maintain the balance 
with the external by establishing an exalted action in 
the secretory vessels, which is manifested in the in- 
creased secretions of viscid saliva. — The secondary 
fever is always in proportion to the extent of suppu- 
rative action, and is dependent upon the loss of 
balance between the two surfaces. By the extensive 
suppuration of the external surface, it becomes the 
primary point of irritation, and hence the afflux of 
blood to this surface. 

From the source and effect of these diseases it is 
evident that in all forms of fever, including exanthe- 
mata, be the cause what it may, the first impression is 
made upon the two systems, as before stated; and we 
find that the fever of this specific disease, from a 
specific cause, clearly proves its uniform specific effect 
upon the two tegumentary systems from the time of 
its incubation to its close. 

My solicitude to establish these two systems and 
surfaces as being invariably the parts first impressed, 
or shocked, by the cause of all acute, and the greater 
number of chronic diseases, is because of the many 
advantages which, in a practical point, may be gained 
in the treatment. And let it be understood, that a chilly 
sensation bespeaks a loss of balance between the two 
surfaces ; and whether from irritation, congestion, or 
inflammation, it should be restored if we expect to gain 
a favorable termination : for by observing the morbid 
vascular action as manifested upon these two surfaces, 



FEVER. 121 

we are enabled to judge of the amount of blood cir- 
culating upon the internal organs from the temperature 
of the external surface, or arising from either irrita- 
tion, inflammation, or congestion ; this is of the 
greatest consequence to the medical attendant. It 
also enables him to determine the nature of all our 
fatal epidemics or endemics, and the force of their con- 
gestive or inflammatory character ; to see the import- 
ance of which, we have but to look at the many absurd 
theories that have sprung up since the entrance of the 
Asiatic cholera into Europe and America, which was 
evidently one of the most fatal congestions of the two 
surfaces in question. 

If these views be correct, and the experience of many 
years teaches me that they are, the system will admit 
of a bold, safe, and decisive practice; and will call into 
use some potent old remedies which, unfortunately for 
the sufferers, have been omitted, in consequence of the 
vacillating opinions on the nature of disease. The 
limits of this essay will not admit of a full description 
of the various indications requisite in the treatment of 
fever. I therefore shall confine my remarks to such as 
will illustrate the additional agents that I have found 
valuable adjuncts in the treatment of the various types. 

General Indications and Therapeutics. 

I. The cause should be removed if possible, and the 
febrile reaction moderated by the lance, cold 
water, and the removal of the vitiated secretions 
from the stomach and bowels, by emetics and 
cathartics. 

II. The gastro-intestinal irritation may be checked, 

11* 



122 FEVER. 

by correcting the secretions of the organs of 
digestion. 

III. The circulation of the two tegumentary systems 

should be maintained as nearly balanced as pos- 
sible, by cold sponging, or by enveloping the 
body in a wet sheet from five to fifteen minutes, 
in proportion to the morbid heat on the external 
surface ; and where the internal capillaries are 
engorged, and the febrile heat confined to those 
parts, mild nauseants, with a warm wet sheet 
wrapped around the body, and rubefacients or 
dry warm applications to the extremities, renew- 
ed every hour, will soon balance the circulation 
between the two surfaces, if the secretions be 
corrected by the use of alteratives. If the fever 
arises from congestion, counter-irritants, fric- 
tion, stimulants, revulsives, bandages, and dry 
cups, of small size, to put the fluids in motion, 
are indicated. 

IV. Where the cause is not known, the effects, as 

observed in their morbid movements on the 
capillary vessels and nerves, should be corrected; 
if the loss of balance be the result of inflamma- 
tion, as in typhus or typhoid fever, the indica- 
tions will be filled by the use of such remedies 
as are best calculated to divert the circulation 
from the parts inflamed, and establish the secre- 
tions. 
V. In specific disease, such as the acute form of the 
exanthemata, as classed by Doctor Eberle, the 
cause, after having produced its effects, cannot 
be removed until exhausted by passing through 
its specific course. Hence the indication will 



FEVER. 123 

be varied agreeably to local determinations. If 
the determination be to the brain, viscera of the 
chest or abdomen establishing inflammation, the 
remedies usually recommended without regard 
to the specific disease, will ansAver the purpose. 
But in these specific diseases, the external tegu- 
mentary system, during the suppurative process 
is liable to become the local seat of inflammation 
or high irritation, which requires a special treat- 
ment, such as sponging the body with cold or 
warm water, to abate the irritation, and equalize 
the excitement, with mild aperients ; and if the 
internal fever be too high to establish or bring 
the eruption to the surface ; the inflammatory 
action and congestion may require the assist- 
ance of the warm bath and nauseating remedies 
to determine the fluids to the surface. 

VI. In intermittent fever, the indications are to be 
met, by clearing out the prima via, and prevent- 
ing the periodical loss of balance between the 
internal and external capillaries ; which may be 
accomplished by wearing flannel next to the 
body, and the use of quinine, opium, and such 
remedies as are usually applied. 

VII. In remittent fever, the use of cold water is more 
frequently indicated than any other remedy. It 
may be applied either by sponging or enveloping 
the body in wet cloths, from five to thirty mi- 
nutes at a time ; or in proportion to the inten- 
sity of the morbid heat. After this the patient 
should be placed in a dry bed, which will inva- 
riably establish diaphoresis, and not unfre- 
quently change the remittent to the intermit- 



124 ' FEVER. 

tent type. This remedy is safe, and more effi- 
cient than any other of the remedial agents 
when the signs for a resort to the cold water 
are manifested. When the chilly sensations are 
alternating, and when the loss of balance be- 
tween the two capillary surfaces, is evident, 
its use would be counter-indicated ; but when 
the morbid heat is high on the external surface 
with alternating chills, which is prima facie evi- 
dence, that the excess of fluids is contained in 
the external capillaries, the use of cold water 
may be resorted to with advantage. But should 
the internal organs contain the excess of the 
fluids, revulsives, counter-irritants and the warm 
wet cloths will be required ; as it will be seen, 
that when the loss of balance between the two 
surfaces is complete, it constitutes an ague ; but 
if the periodical congestion becomes confirmed 
upon the internal organs, we have a violent chill 
followed by a continued form of fever, which 
may be subdued by the influence of cold water, 
and the form of the fever changed to an inter- 
mittent type. But should the congestion be 
confirmed to a greater or less degree upon the 
organs of the three cavities and the external 
capillaries, the remedies to meet such alarm- 
ing condition, are to be found in the agents 
that are best calculated to produce reaction of 
the system, and put the circulating fluid in 
motion; which, in some constitutions, may be 
effected by small dry cups, applied on various 
parts of the body and extremities, and with 
gentle friction, assisted by cathartics, in order to 



FEVER. 



125 



produce reaction ; but in others, it will require 
the use of a roller, applied to the extremities, (so 
as to force a movement of the fluids in the 
superficial blood-vessels,) assisted by friction, 
blood-letting and warm brandy toddy, to re- 
establish the circulation. In some of the severe 
forms of congestion, where the arteries are not 
contracted, a sudden douche of cold water, 
when the patient is not expecting it, is an ad- 
mirable reactive agent. But if the pulse has 
become thready, this treatment is contra- 
indicated. 
VIII. In irritative, continued, typhus or typhoid fever, 
cold water is indicated to a greater or less ex- 
tent. In its application, the same rules, as in 
the remittent form, are to be observed. 
IX. In the treatment of all forms of fever, where the 
mucous coat of the bowels becomes the seat of 
inflammation with or without diarrhoea, the 
roller should be used with the pledgets as 
directed in the essay on mechanical agents, to 
moderate the peristaltic movements, and to pre- 
vent tympanitis from the gravitation of the 
bowels whilst over the close stool. On return- 
ing to bed, the patient should always lie on his 
right side for a few minutes, with his hips ele- 
vated, to restore the bowels to the abdominal 
cavity. 
X. In cases of confirmed congestion, in the com- 
mencement, or during the progress of the dis- 
ease, with the heat of the extremities below the 
standard of health, the bandage and cups should 
be used as directed in cholera. 



126 FEVER. 

XI. During the progress of fever, when it arises 
from the inflammation of the organs of the 
chest, cold water is counter-indicated. 

In these brief and partial outlines of therapeutic 
and general indications, I have not thought it neces- 
sary to enumerate the remedies in daily use, and 
which are understood by the profession. To have 
done myself justice, my remarks in many places should 
have been extended, and my principles more fully 
demonstrated ; but health forbids, and as there is suf- 
ficient in the several essays to determine the correct- 
ness of the position, I must leave to the investigating 
mind, or to the future, the further illustrations of so 
important a subject. 



DISPLACEMENT OF THE WOMB. 



The displacement of this organ, under the variety 
of forms to which it is liable, with constipation of the 
bowels and its consequences, has been, and still con- 
tinues to be, the bane and scourge of the female sex. 
The womb being situated between two cavities, with 
only the round and broad ligaments, septa, and 
the relative cellular attachments to sustain it, the fre- 
quency of the displacements is hardly to be wondered 
at : but when we look at the viscera of the abdomen, 
ready at all times when the axis of the body is changed, 
to press upon the fundus uteri — and the smooth 
curved plain ever ready to receive it in its descent — 
at the portion loosely attached to the vaginal mem- 
brane, the rectum, and the bladder, we can have no 
doubt as to the cause of the disorder, and the necessity 
of directing the best energies of the profession to its 
cure. The doctrine that has crept into the minds of 
some of the profession, both in Europe and America, 
that the vaginal membrane supports the womb, and 
that the efforts for its cure must be directed to that 
tissue, is so absurd, and so directly opposed to what is 
proved by the anatomical arrangement, that argument 



128 DISPLACEMENT OF THE WOMB. 

would seem hardly necessary to refute it. It is be- 
lieved, and the position is acted upon by gentlemen 
who have attained some character in the profession, 
that anatomy demonstrates most clearly that the sup- 
port of the organ depends upon the peritoneal attach- 
ments and its connexion with other organs. But let 
us look at facts instead of theories. 

This organ is situated between the abdominal and 
pelvic cavities, sustained by its ligaments, and sup- 
ported in its erect position by two septa between 
it and the badder anteriorly, and between it and the 
rectum posteriorly ; either of which when relaxed will 
allow the womb to become displaced ; and as one or 
the other is often stretched, they are a frequent source 
of displacement and derangement of the functions of 
that important organ. Cold is, perhaps, the most fre- 
quent exciting cause of uterine disease. The womb 
being debilitated by displacement is less capable of re- 
sisting the shock produced by cold, which rarely ex- 
cites a disposition to disease. 

The predisposing causes of the disease of the uterus 
and its appendages to be named hereafter, are as fol- 
lows, viz. : gravitation of the bowels from sedentary 
habits, constipation, diseases of the rectum, over- 
distension of the bladder, mechanical injury, over- 
reaching, too frequent child-bearing, sudden con- 
cussion upon the abdomen, tight lacing above the 
umbilicus ; and heavy lifting. 

These causes, although many, are the consequence 
of other causes ; yet gravitation of the bowels, consti- 
pation, and disease of the rectum, may be considered 
as the principal antecedent causes of prolapsus uteri, 
while retroversion, anteversion, dysmenorrhea, hys- 



DISPLACEMENT OF THE WOMB. 129 

teria, fluor albus, chronic enlargements, and neural- 
gia, are all referrible to the above-mentioned con- 
ditions as their antecedent causes. Many organic 
diseases derive their origin from the same sources, and 
in clinical practice, there is no class of diseases more 
frequently met with than those above enumerated. 
The organ is subject to depression in a direct line, or 
by an inclination of its fundus, most frequently back- 
ward, and toward the left side; though sometimes in a 
different direction. 

The symptoms of prolapsus vary according to 
the descent and direction of the fundus, and the ante- 
cedent causes of the displacement. If the small intes- 
tines rest equally on the lateral ligaments, a sense ot 
fulness and bearing down weight, with pain and weak- 
ness of the back and loins, are complained of. If the 
sigmoid flexure be the cause, the patient will frequently 
complain of pain in the left side, and a sense of fulness 
in the rectum, with obstinate constipation. And when 
the loaded condition of the rectum is the cause, symp- 
toms simulating those of gravel ensue. Most fre- 
quently displacement of the womb is neglected until 
the.bladder, rectum, and vaginal membrane are affected, 
before the physician is consulted, when a combination 
of symptoms occur ; such as a sense of weakness and 
pain in the back, with dragging or bearing down sen- 
sations, as if something was about to pass, with fre- 
quent leucorrhceal discharge, and sometimes stran- 
gury. Where the fundus of the uterus rests upon 
the rectum it very much increases the violence of the 
bearing down pains, producing a sense of fulness and 
pain in the abdomen. In such a case, the fundus is 
found below the promontory of the sacrum, with the 

12 



130 DISPLACEMENT OF THE WOMB. 

os uteri resting under the symphysis pubis. This form 
of displacement is most frequently met with in preg- 
nancy, yet it is found in the unimpregnated state also, 
though rarely. 

The constitutional symptoms attendant on these dis- 
placements, are necessarily various. In some, the 
general health suffers periodically, whilst in others, the 
strength is reduced and the variable symptoms of dys- 
pepsia and hysteria are prominent. The nervous con- 
nection is so intimate between the organs of the pel- 
vis and the abdomen, that the symptoms frequently 
invade the entire system. At other times the heart 
apparently receives the shock ; and thus all the organs 
in the three cavities are liable to morbid nervous de- 
rangement from the same source — displacement of 
the womb resulting from the diseases of the rectum, 
bladder, and vaginal membrane. Hence, where the 
female has lost, or is about to lose her health, the 
first thing to determine is, the real condition of the 
organs of the pelvis ; since the symptoms arising 
from disease either of the womb, rectum or bladder are 
present when one or all of these affections exist. I 
have met with cases where one or two small fleshy 
tumors in the rectum, within the action of the levator 
ani muscle, had been treated for disease of the liver or 
heart. Again, I have found all the symptoms of dis- 
placed uterus arising from over-distension of the rectum 
and engorgement of the blood-vessels. When, therefore, 
the organs of the pelvis are believed to be the seat of 
disease, I direct the patient, lying on her right side, to 
elevate her hips, when the symptoms will disappear if 
the disease be prolapsus or procidentia, produced by 
the weight of the superincumbent viscera. But if the 



DISPLACEMENT OF THE WOMB. 131 

prolapsus be produced by disease of the rectum, the 
relief will be but partial, and will return as soon as the 
erect position is resumed. When the disease is com- 
plicated, examination by the touch is necessary to de- 
termine its true character. 

The weight of the abdominal viscera sometimes 
produces what is called anteflexion or retroflexion of 
the fundus of the womb, while the os uteri rests against 
the curved plain of the vagina. These flexions produce 
an angle in the cervix uteri which is a fruitful source 
of dysmenorrhea, sterility and chronic thickening of 
the tissues of the organ. To enable the reader to com- 
prehend my views in relation to the several diseases 
connected with the subject, and to show that the cause 
and effect are in conformity with the anatomical ar- 
rangement of the pelvic organs, I lay down the follow- 
ing propositions, viz : 

I. The womb is suspended between the upper boun- 
dary of the true pelvic cavity, and the lower 
boundary of the abdomen, and between the 
rectum and bladder, by the duplicatory attach- 
ments of the peritoneum and two septa, which 
are its natural support. 
II. The vaginal membrane is attached to the lower 
boundary of the womb, peritoneum, and the 
urethra under the symphysis pubis, and were 
it not for these attachments the slightest debi- 
lity would bring on prolapsus of the vaginal 
membrane as frequently as the inner tunic of the 
rectum is prolapsed. 
III. The vagina alone is incapable of affording any 



132 DISPLACEMENT OF THE WOMB. 

support to the womb in its primitive attitude, or 

of resisting its descent. 
IV. As long as the ligaments and septa maintain their 

energy, there can be no misplacement of the 

womb, unless by violence. 
V. Prolapsus uteri, procidentia, retroflexion and ante- 
flexion rarely result from disease of the womb ; 

but from debility, or extension of its ligaments. 
VI. The indications here, are to restore the ligaments 

to their healthy condition, by removing the 

cause. 

Treatment. 

In the treatment of these several diseases origina- 
ting from a depressed or altered condition of the 
organ, the following principles should be kept in view. 
First, no two cases of displacement are in all respects 
exactly alike, in their antecedent or exciting causes ; as 
their constitution, habits, complications, functional or 
organic alterations vary. Hence the most simple form 
of prolapsus, in different constitutions, will require a 
difference in their treatment. For instance, the treat- 
ment differs if it has been the consequence of different 
causes, as sedentary habits, constipation, disease of 
the rectum, over distension of the bladder, too fre- 
quent child-bearing, leuchorrhoeal discharge, chronic 
enlargement of the womb, constitutional disease, me- 
chanical injury, tight lacing, sudden concussions, &c. 

The indication in derangement of the womb in 
one, is to cure the constipation and restore the strength 
of the ligaments ; in a second, to cure the disease of 
the rectum, and in a third, to support the abdominal 
viscera, and invigorate the muscular system. For the 



DISPLACEMENT OF THE WOMB. 133 

sake of illustration, I will suppose a case of each of 
the most prominent misplacements. 

I. Prolapsus uteri, produced from sedentary habits, 
relaxed muscular system and gravitation of the bowels. 
The remedial agents are partly mechanical, as the dis- 
ease originates from a failure of the physical functions, 
and may be successfully met, by placing the patient upon 
the right side, and elevating the hips with the thighs 
flexed, and the body inclined forward, which brings 
the axis of the superior and inferior strait in the same 
line. This position continued fifteen or twenty mi- 
nutes will suffice to restore the bowels to the abdo- 
minal cavity, and the womb to its natural position, 
where a suitable supporter will prevent the recurrence 
of visceral displacement. The description of the in- 
strument, and the mode of applying it, will be given 
in a subsequent essa}^. After the application of the 
supporter, the cure may be completed by aperients, 
alteratives, cold sponging, or shower bath every morn- 
ing, with exercise in the open air. 

II. Procidentia, produced from distension and gra- 
vitation of the bowels. The mode of restoring the 
bowels, and the application of the supporter in this is 
the same; but in some cases the uterus is so far 
descended, that the horizontal position is required to 
be continued for several days, when gentle pressure 
of the hand will readjust the organ. After which the 
indications are, to restore the rectum, with the reme- 
deis recommended for the treatment of that organ, 
and apply cold water, or green tea, as a wash for the 
vagina. The cause of distension of the bowels and 
rectum in such cases must be removed, and the con- 

12* 



134 DISPLACEMENT OF THE WOMB. 

stitutional symptoms treated by alteratives, tonics, 
cold sponging, and moderate exercise. 

III. Retroflexion and Anteflexion are the conse- 
quences of the superincumbent pressure of the abdo- 
minal viscera, and force of the diaphragm, which pro- 
duce a bend in the neck of the womb. This may be 
readily removed by the use of the supporter, with 
alteratives and aperients to restore the functions of 
the organ. 

IV. Retroversion of the uterus is a disease most fre- 
quently met with in the first months of pregnancy, and 
is a displacement backwards, with its fundus below the 
promontory of the sacrum, the os uteri being thrown 
forward under the symphysis pubis, where it presses 
upon the urethra, producing strangury, whilst the 
fundus is resting upon the rectum in its descent along 
the curve of the sacrum. The symptoms are violent 
bearing down pains, with a sense of fulness in the 
passage, and pains in the lower part of the abdomen, 
which are principally owing to distension of the 
bladder. 

The treatment, after the organ is restored to its 
natural position, consists in wearing a supporter until 
the first three months of pregnancy have passed. The 
patient should frequently void her urine, or have it 
drawn off, if there be any obstacle, as constipation, 
distension of the bladder, with the weight of the 
viscera of the abdomen, which are the chief causes of 
the difficulty. The best mode of detecting this disease 
is by an examination of the passages. After the blad- 
der has been emptied, and the organ restored to its 
proper elevation, the cure is completed with the sup- 
porter and aperients. 



DISPLACEMENT OF THE WOMB. 135 

In the treatment of anteversion I am enabled to pre- 
sent a case that was evidently produced from consti- 
pation and a morbid condition of the rectum. During 
three years, as related by the patient, she had passed 
from three to eight days without a passage from the 
bowels. Piles were established, after which the uterus 
became deranged, and chronic enlargement ensued, 
especially in the front portion, which was made to rest 
firmly against the bladder and pubis. The round liga- 
ments appeared to have participated in the chronic 
affection, as they appeared to be double or treble their 
natural size. From what I learned from the patient, 
who was quite intelligent, and from the result of the 
treatment, I have no doubt the disease was produced by 
the loaded condition of the rectum and sigmoid flexure 
of the colon. The former, by its distension, carried 
the organ forward ; whilst the latter, in its impacted 
condition, descended against the fundus, which evi- 
dently established irritation of the uterus, and thereby 
increased the morbid action. The sigmoid flexure, 
when over-distended, in its descent was checked by the 
fundus of the uterus, which was thrown from the sacrum 
by the impacted rectum, and pressed forward upon the 
bladder and pubis. This fact was ascertained by 
repeated examinations. When the lower bowel was 
loaded, the angle of the sigmoid flexure was found 
pressing downwards at the promontory of the sacrum 
like a tumor behind the fundus uteri, which was re- 
moved by purgatives and injections. This condition, 
with the hemorrhoidal tumors, further established the 
fact, that the disease had been produced by constipa- 
tion and the descent of the sigmoid flexure of the 
colon. The sigmoid flexure, in several cases of dys- 



136 DISPLACEMENT OF THE WOMB. 

menorrhcea attended with constipation, has been found 
in the same position, or nearly so, resting partly upon 
the fundus and promontory of the sacrum, giving the 
organ a weight equal to what it attains in two and a 
half months of pregnancy. This corroborating evi- 
dence, and the success in the treatment, leaves the 
question in relation to the cause beyond a doubt. 
The treatment of this case of anteversion was the same 
as recommended for constipation and disease of the 
rectum, with a few additional remedies, such as cup- 
ping, hip bath, antimony, with a pill of two grains ex- 
tract conii every night, combined, occasionally, with 
from three to five grains of blue mass, and the daily 
use of the saturated tincture of the apocynum canna- 
binum, to regulate the secretions. This tincture, in all 
cases of chronic enlargement, or neuralgia of the 
womb, will be found a valuable remedy. It should be 
given in doses of from a half to a whole drachm, three 
times a day, or in the quantity sufficient to regulate 
the bowels. Where it is given for chronic neuralgia, its 
powers are enhanced by the tincture of guaiac. in equal 
parts, given three times a day. For twenty years I 
have almost exclusively relied upon these two articles 
in chronic disease, and functional derangement of the 
womb, such as dysmenorrhcea and its consequences. 
But its quality and uses are more generally discussed 
in another essay. 

Therefore, with the supporter and the remedial 
agents herein recommended, in conjunction with the 
remedies advised by systematic writers, for these dis- 
eases, the scourge of the female sex will be under the 
control of the experienced physician. 



DISPLACEMENT OF THE WOMB. 137 

For the use of the pessary, and its application when 
admissible, see the Essay on Mechanical Agents. 

The following Essay, which was published in an- 
swer to the Theory of Professor Meigs, will further 
elucidate the subject: — 

The Diaphragm, it will be observed, is a complete 
movable septum, placed between the thoracic and ab- 
dominal cavities, and is extremely concave below, and 
convex above, the lower cavity being occupied by part 
of the abdominal viscera. This septum converging, as 
it does, from the circumference of the thorax, is a 
highly important anatomical structure. On each side 
of the cordiform tendon the muscular fibres rise so high 
before they join it, that their horizontal line is level 
with the anterior end of the fourth rib. Thus it will be 
observed that its form is nearly circular. It is fleshy at 
its circumference, and aponeurotic in the middle. An- 
teriorly, it is attached to the ensiform cartilage ; late- 
rally, to the internal surface of the cartilages of the six 
last ribs ; posteriorly, to the transverse processes of 
the first lumbar vertebra; by its left pillar, to the 
bodies of the three first vertebrae of the same region, 
and by its right pillar, to the bodies of the four first. 
Consequently, the structure of the diaphragm consists, 
in part, of a three-lobed aponeurosis, termed the 
Phrenic Centre. The upper surface is connected with 
the pericardium, the mediastinum, and the pleura. Its 
lower surface, posteriorly, is in contact with the kid- 
neys, the supra-renal capsules, the pancreas, and the 
duodenum, on the right side, with the liver; and on 
the left, with the spleen and stomach ; in the whole 
extent of the lower surface, it is covered by the perito- 



138 DISPLACEMENT OF THE WOMB. 

neum. In the mechanism of respiration, the diaphragm 
performs a most important office. In coughing, vomit- 
ing, laughing and speaking, it is alike a principal 
agent, and assists in various functions, such as the 
expulsion of the contents of the intestines, the bladder 
and the uterus. 

The Peritoneum is the next object in connection 
with the subject. " This is a thin, delicate, semi-trans- 
parent membrane, very extensive and spread out so 
as to line the cavity of the abdomen, and to give an 
external covering to the greater number of its viscera. 
In men it is a complete sack, having no opening in 
it ; but in women, its cavity communicates externally 
through the fallopian tubes." It has a two-fold use: 
the first is to cover the viscera and tie them down to 
the back and sides of the abdomen; the second is, in 
consequence of covering the viscera, so reflected to 
the sides of the abdomen that its processes keep the 
viscera in their proper places, and consequently act as 
ligaments to the organs contained within the cavities 
of the abdomen and pelvis. The liver is fastened in 
its position by the reflection of the peritoneum, as fol- 
lows: — From the centre of the diaphragm, and extend- 
ing from the umbilicus backwards, to near the ascend- 
ing cava, are the falciform, or suspensory ligaments. 
The round ligament, the right lateral ligament, and 
the portion of the peritoneum concerned in the union 
of these, form the coronary ligament, &c. 

Thus, it will be seen, that the peritoneum, by its 
ligaments and reflections, not only suspends the liver to 
the diaphragm, but is so adjusted as to give the neces- 
sary attachments to the greater number of the viscera 
contained within that cavity. 



DISPLACEMENT OF THE WOMB. 139 

Having thus examined the ligaments and reflections, 
that sustain the viscera of the abdomen, our attention 
will be directed to the ligaments and reflections that 
sustain the organs of the pelvis. The ligaments of 
the bladder are the urachus, which proceeds from 
the fundus to the navel, forming a long conical liga- 
ment, and on each side of this ligament, are the 
remains of the umbilical arteries of the foetus, which 
are called the round ligaments of the bladder. Besides 
the above three ligaments, it receives a complete coat 
from the periotenum, which being attached to the 
upper and posterior parts, and passing thence to the 
muscles of the abdomen before, and the uterus behind, 
forms the anterior ligament. 

The uterus is a compressed pyriform body, with a 
cavity in its centre, and is placed between the bladder 
and the rectum, with the small bowels above, and the 
vagina below. Professor W. E. Horner says, "it is 
maintained in its situation, in the centre of the pelvis, 
by the reflections of the peritoneum, which are called 
ligaments." The peritoneum, after covering the uterus 
completely, is reflected anteriorly upon the bladder, 
and at each side of this, is a reflection of the membrane 
denominated the anterior ligament, which goes to the 
urinary organ. The peritoneum in passing from the 
back part of the uterus to the vagina, and rectum, has 
on each side of the reflection, a duplicature, which 
constitutes the posterior ligament. It is also reflected 
from the whole length of each side of the uterus, to the 
corresponding part of the cavity of the pelvis. These 
reflections are the lateral, or broad ligaments, which, 
with the uterus, form a transverse septum in the middle 
of the pelvis. Besides the ligaments mentioned, the 



140 DISPLACEMENT OF THE WOMB. 

uterus has two others, one on each side, called the 
round ligaments. They arise from the sides of its 
body, between the duplicatures of the broad ligaments, 
and pass under the peritoneum, to the abdominal ring, 
through which they pass, and are lost upon the fat of 
the mons-veneris and the labia-majora. They are of 
a fibrous structure, and contain many blood-vessels. 

Having finished the anatomical arrangements of the 
diaphragm and peritoneum, in connection with the 
viscera of the abdomen and pelvis, I will now proceed, 
2dly, To present what I consider as the results of such 
an organization. 

The form of the diaphragm, which is a conical 
arch, and made up from suitable origins, was designed 
to have great strength for the performance of its func- 
tions in the healthy state. Every time we draw our 
breath, it contracts, and changing its vaulted form to 
that of a plane, it enlarges the capacity of the chest, 
so as to permit the dilatation of the lungs. At the same 
time it forces the viscera which are loosely attached, 
downwards, and the muscles of the abdomen outwards, 
and is, consequently, the principal muscle of inspira- 
tion ; on the other hand, when it relaxes, the abdominal 
muscles press their viscera upward, the diaphragm is 
fored up into the thorax, made to compress the lungs, 
and thus to contribute to expiration. These movements 
are anatomical and physiological ; and, in examining 
the causes which produce debility of the muscles of 
the abdomen, or alteration of the peritoneum, at 
its processes or ligaments, we may inquire what it 
is that prevents the bowels from descending into the 
lower portion of the abdomen or cavity of the pelvis ? 



DISPLACEMENT OF THE WOMB. 141 

What barrier has the pelvic viscera against the 
encroachment of the viscera of the abdomen ? This 
question I proceed to answer. The anatomy of the 
parts shows that the line passing around the pelvis, 
on a level with the promontory of the sacrum, is the 
narrowest point in the pelvis. The psoas magnus, the 
iliacus, and obturator internus, passing over, and part 
of them having their origin within the pelvis, assist in 
narrowing this boundary still further. Hence it is 
seen, that by this part of the bony and fibrous struc- 
ture, with the admirable arrangement of the perito- 
neum, in giving a coat to the uterus, and by the broad 
ligaments attaching it to the walls of the cavity, there 
is formed another arch, or floor, below as an antago- 
nist to the diaphragm above. 

The round ligaments being of the same fibrous 
structure as the uterus, about the size of a goose-quill, 
proceeding from the sides of that organ, and passing 
out through the abdominal ring, to be inserted into 
the mons veneris and labia majora, are governed by 
the same physiological laws as the uterus itself. 
Whilst the uterus is in its unimpregnated state, these 
ligaments have but little influence, but as soon as that 
organ is impregnated, and commences its growth and 
ascension, we find them increased by nutrition, both 
in tension and in length, and thus enabled, during the 
ascent of the uterus, to maintain it in contact with the 
anterior walls of the abdomen. Thus, as soon as the 
term of gestation is completed, these ligaments and 
the uterus contract upon themselves, until each is 
reduced to their primitive condition. They are also 
the support which prevents the weight of the uterus, 

13 



142 



DISPLACEMENT OF THE WOMB. 



with its contents, (by maintaining it in its proper 
position,) from deranging the organs of digestion. 

But a recent writer on Retroversion, in sundry 
letters to his pupils, says: "It is a diseased or debili- 
tated state of the round ligaments that gives rise to the 
disorder." "The cure," he continues, "consists in the 
restoration of the health and tone of these ligaments." 

The scalpel, however, with the analysis of the 
tissues, and observations of the various writers on 
anatomy, show that this hypothesis is not sus- 
tained, and that the author has entirely misappre- 
hended that it. is the reflection of the peritoneum, 
including the ligamenta rotunda, that prevents retro- 
version, and not the round ligaments alone. 

The following cut of the uterus with its peritoneal 
coat removed, presents the muscular fibres, marked 
b b on the external surface of the uterus, terminating 
in the round ligaments marked a a. This drawing 
fairly demonstrates the character of these ligaments 
and the offices they are intended to perform. 




DISPLACEMENT OF THE WOMB. 143 

Blundel says, " The round ligaments, two in num- 
ber, originate from the superior lateral parts of the 
uterus. They run into the doublings of the broad 
ligaments, and, rising to the brim of the pelvis, pass 
over it, through the abdominal ring, and lose them- 
selves, as it were, in the mons veneris and the groin?. 
They are composed of arteries, veins, lymphatics, 
nerves, and fibrous structure united together by cellular 
membrane. Though small in the unimpregnated state, 
they become developed by gestation, lengthen, spread, 
and are more vascular." 

The author of Females and their Diseases is likewise 
frightened at the "remedial agent called a Supporter," 
and not in the language, but in imitation of Hamlet, calls 
upon his students to look upon " the grim and ghastly 
representative of our poor mortality," and to follow 
him through the denunciations he has "extracted from 
his brain" to expose the indiscretions of his brother 
professors. " Don't you see," he exclaims, " that if you 
draw a line from the pubis to the xiphoid cartilage, it 
will represent the linea alba of the grim horror ? Look 
again and observe the place where the mesentery was 
attached, and the root of the meso-colon too ?" Yes, 
my young friends, look again and again, and examine 
for yourselves the linea alba, made up from the ten- 
dons of the muscles and fasciseof the abdomen. Look 
at the origin and insertions of the two obliqui externi, 
the two obliqui interni, the two transversales, the rectus 
abdominis, the two pyramidales, and the serratus mag- 
nus, and make yourselves familiar with their several 
offices. Look and admire how wonderfully they assist 
respiration, sustain and compress the viscera of the 
abdomen, and antagonize the force of the diaphragm. 



144 DISPLACEMENT OF THE WOMB. 

s 

Look also at the uterus, and contemplate the relative 
parts placed there by the God of nature for its support. 
These attentions and practical observations will tell 
you that where the muscles become debilitated by 
child-bearing, or other causes, they have need of sup- 
port, not only from the remedial agent so much abused, 
but from all the remedies brought into use since the 
time of Esculapius. It is, indeed, true, that " we are 
fearfully and wonderfully made ;" but were we to follow 
the doctrines of the worthy professor, with his uterus 
perched upon the vagina, we should have the best 
reasons in the world for alarm. But as the work con- 
tains much that is foreign to the subject, we must look 
to the fathers of the science, who took nature for their 
guide, and thence derived information calculated to 
mitigate the affliction of the human family. If he had 
even looked into Pope, the text is made out to his 
hand, and instead of drawing upon fancy or the credu- 
lity of his pupils, much might have been saved to his 
readers. This writer says : 

" First follow nature, and your judgment frame 
By her just standard which is still the same; 
Unerring nature, still divinely bright, 
One clear, unchanged, and universal light, 
Life, force and beauty, must to all impart 
At once the source, and end, and test of art." 

But, that his " brother anatomists" who have 
" paraded their names in the newspapers," and that 
those interested, may contemplate his incomparable 
arguments, the following extract, from page 188, will 
answer: — "Now," says the Author, "take a utero- 
abdominal supporter, and adjust it as the mesmerized 
do, mentally upon the skeleton, and you will see that 



DISPLACEMENT OF THE WOMB. 145 

it can have no effect to hold up the bowels ; that it 
can only push your fancied tractus of the linea alba 
backwards against the spinal column ; and with what 
effect, pray ? Surely, with none other than one of en- 
croachment on the capacity of the abdomen. Do you 
not see that the belly of a living man or woman is a 
vacuum plenum ? How can you hold up the bowels by 
a pad? If you could thrust them upwards in the 
vacuum plenum, which you cannot do, you would only 
thrust them towards the concave of the diaphragm. 
But the diaphragm must come down, or the woman 
will die — she can't breathe but by the descent of her 
diaphragm. Her diaphragm is her respiratory piston, 
and the trunk of the body is the cylinder in which 
this piston moves downward in the aspiration, and 
upwards in the expiration of the air of the atmos- 
phere." 

But here, you will observe, although the arguments 
are forced and contradictory, that if the parietes of 
the abdomen are " forced backwards against the spinal 
column," as he tells you, it must follow that the vis- 
cera of the abdomen must be prevented from encroach- 
ing upon the organs of the pelvis, — the very mischief 
that is to be overcome. 

" But your utero-abdominal supporter," he continues, 
"knows better than the Providence that made this 
great machine ; and he is about to make the piston 
work half strokes in breathing; like an engine that 
one is afraid of." Half strokes in breathing ! This, 
gentlemen, might be true ; but where can you find the 
practical engineer, who would apply a half force where 
no force is wanted ? Would he not exhibit his judg- 

13* 



146 DISPLACEMENT OF THE WOMB. 

ment by confining his piston within its proper limits, 
and guard against over or under action ? 

Our author has also forgotten the comparative 
weight of the various organs which are dependent for 
their support on the peritoneum, and of course has 
reversed the principle that invariably governs the prac- 
tical anatomist. The weight of the liver is forty times 
greater than that of the uterus and its appendages, and 
when we look at the two organs, and their fixed points 
of attachment, we shall discover that the uterus is 
more secure than the liver. But as the work is con- 
sidered ephemeral, intended only for a class in the rudi- 
ments of medical study, it is presumed that the works 
of his distinguished cotemporaries will not suffer by 
its publication. 

On prolapsus uteri he is alike emphatic, and without 
qualification maintains his position. He says, " pro- 
lapsus uteri is a disease of the vagina, not of the 
womb. To cure prolapsus uteri, you are to seek to 
cure the vagina, and when you have done that, the 
womb will be found cured also." This declaration, 
when traced to its source, is incredible. To me " 'tis 
passing strange!" that one of the most important or- 
gans, designed by the Creator of the universe for 
" replenishing the earth," should be propped up by so 
feeble a support as the vagina. But, in order to deter- 
mine the validity of such doctrine, let us take a cur- 
sory view of the vagina, in connection with its relative 
parts. The levator-ani muscle is very thin, and by its 
attached portions it acquires a funnel shape, and has 
two-thirds of its fibres inserted into the circumference 
of the rectum ; the remaining third, into the bones 



DISPLACEMENT OF THE WOMB. 147 

of the os coccygis, the vesicle end of the urethra, pros- 
tate gland, and the point of the perineal muscle. The 
triangular ligament is to be viewed in its relation to its 
several attachments, and its connection with this muscle 
and the aponeurosis pelvica ; from which it will be seen 
that the levator has a double office to fulfil. The first 
is to draw up the rectum after the contents have been 
removed or expelled ; the second, to assist the sigmoid 
flexure of the colon in sustaining the contents of the 
intestines which are made by the peristaltic and ver- 
micular motion to gravitate to the natural outlet: 
otherwise, the rectum would be under the constant 
solicitation to part with its contents. The coccygis 
is a thin, flat, triangular muscle, originating from the spi- 
nous process of the ischium. Its fibres diverge, and are 
inserted into the border of the os coccygis ; it secures 
this bone in its station. The sphincter-ani muscle is 
of an oval figure, open in its centre, its fibres surround- 
ing the extremity of the rectum, or anus. It is 
attached to the os coccygis, by a species of cellular 
tendon, from whence two fleshy fasciculi proceed, 
uniting together in front of the anus. The upper mar- 
gin is connected with the levator ani by cellular tissue. 
This muscle closes the anus, and, in the male, draws 
down the bulb of the uretha. The ischio-cavernosus 
is a small elongated muscle, placed along the ramus 
of the ischium, and the root of the corpus cavernosum 
in the male. This muscle terminates in the female, 
by embracing the corpus cavernosum of the clitoris. 
The transversus perinei is a flat, thin muscle, attached 
on its outer part to the ramus and tuberosity of the 
ischium — on the inner part to the middle line, with its 
fellow on the opposite side. This muscle supports the 



148 DISPLACEMENT OF THE WOMB. 

lower part of the vagina, rectum, and bladder. The 
constrictor vagina consists of a number of muscular 
fibres, forming a sort of broad fleshy ring, surrounding 
the vagina. This muscle contracts the part which it 
embraces, viz : the labia externa and interna or nym- 
phae, the clitoris, and the vestibulum, the fourchette, or 
frenum vulvee, and the hymen in the virgin state. 
These, with the above named muscles, are found within 
the region of the pelvis and vagina, and their uses and 
purposes are fully described in any of the anatomical 
works. 

Professor W. E. Horner says: "The vagina is the 
intermediate part of the sexual organs. It extends 
from the vulva to the uterus, being placed between the 
bladder and rectum, compressed anteriorly and pos- 
teriorly by them. It is a membranous canal, of from 
four to six inches in length, differing according to age 
and pregnancy, being much shorter in women who 
have borne children than in virgins : its shape varies 
somewhat near the vulva ; but its greater diamater is 
vertical; behind, near the uterus, the greatest diame- 
ter is transverse ; its anterior and posterior surfaces 
are in contact, from the circumstances just mentioned, 
of pressure between the bladder and rectum ; it is 
shorter before than behind, corresponding in this 
respect with the pelvis by which it is influenced, and 
also in consequence of being attached to the uterus 
higher up on the sacral than on the pubic side. 

"The peritoneum, in descending from the uterus 
anteriorly, touches the top of the vagina for a little 
distance, and is then reflected to the bladder; but 
posteriorly, nearly the upper half of the vagina has a 
peritoneal coat, before this membrane is reflected to 



DISPLACEMENT OF THE WOMB. 149 

the rectum. The attachment of the vagina to the 
bladder is strong and close just above the urethra, 
but its connection to the rectum is by rather loose 
cellular membrane. 

" It consists of two coats, a fibrous and elastic one 
externally, and a mucous one internally. The first is 
of a reddish color, and seems to be formed of con- 
densed cellular membrane, its fibres not passing in any 
determinate direction; many blood-vessels are found 
in its structure, and it has an abundance of large 
venous sinuses surrounding it." From a survey of the 
anatomical structure, and from my own observations 
in dissection, I wholly dissent from the author of the 
forty-two letters, and am clearly of the opinion that, 
instead of the vagina supporting the uterus by its 
attachments to that organ, it imparts to it but little 
strength, and receives its own support from the con- 
nection with the peritoneum. 

Such being the facts, when we consider the object 
and offices of the several muscles, membranes, &c, 
of this department, in what possible position can we 
place them, to represent the "pelvic floor" of the 
learned professor ? If his position is right, his anatomy 
is wrong, and if prolapsus is a disease of the vagina, 
then is he wrong in his therapeutics, and how can he 
exclaim to his pupils " cure the vagina and you cure 
the disease?" But from the facts before us, would it 
not be better or more in accordance with the science, 
and his own pathology, to have regulated the bowels 
by aperients and alteratives, by simple and medicated 
enemas, by alum and water to restore the tone of the 
levator and rectum, to meet and resist at the proper 
point the superincumbent weight of the viscera of 



150 DISPLACEMENT OF THE WOMB. 

the abdomen, and by the use of cold water in the 
vagina] membrane, with astringents and styptics, 
according with the pathology of the parts, rather than 
divert his pupils with an insufficient prop to the uterus 
or force upon the profession an imaginary floor, that 
is not sustained by the anatomical arrangement. 

By my experiments on the dead subject, I have 
found after removing the vagina and leaving the 
uterus with its peritoneal attachments and round liga- 
ments only, a considerable weight was necessary to 
force it from its position. This fact was realized by 
the dissection in two different ways. The first by 
removing the lower portion of the os coccygis with 
the same extent of the rectum and vagina, leaving 
the fourchette entire. This brought in view the uterus 
in its proper position, with the upper portion of the 
vagina and its attachment to the uterus and perito- 
neum. The second by removing the vagina with half 
the portion of the perinei muscles and fourchette, so 
as not to interfere with the rectum. These modes of 
dissection enabled me to determine the amount of 
support the uterus derived from the vagina. By 
making a transverse section from one ilium to the 
other, and by removing the upper portion of the walls 
of the abdomen to the sternum, and cartilaginous 
portion of the ribs, I was enabled to judge of the 
support the ligaments give to the organs of the pelvis. 
Then placing a block under the subject at the lumbar 
region, the anterior part was put on the stretch, and 
the bowels being thrown upwards, the organs were 
brought clearly into view. The hypogastric and 
inguinal region being now made tense, by the tenacu- 
lum, the urachus and round ligaments dissected away, 



DISPLACEMENT OF THE WOMB. 151 

to expose the upper portion sufficiently to enable me 
to hold those with forceps, (the bladder being inflated 
in order to represent the distension brought on by 
retention of urine,) I could then ascertain the degree 
of pressure, exerted upon the uterus in different direc- 
tions, and determine the strength of the ligaments 
when put on a stretch in the various displacements of 
that organ. I admit that the disease of the one may 
affect the other, but that the cure of prolapsus is 
solely dependent upon the cure of the vagina is a gra- 
tuitous assumption, sustained neither by facts nor 
argument. On the contrary, I contend that the uterus 
is sustained in its appropriate situation by the broad 
and round ligaments, aided by the utero-vesical and 
utero-sacral ligaments ; and that while these ligaments 
retain their healthful tonicity, the uterus could not 
descend, even if the alleged vaginal support were 
removed by the scalpel. Besides, should these liga- 
ments become relaxed, the uterus will descend not only 
into the vagina, but pass through it, and hang outside 
of the vulva. Churchill says, " it is produced, first, 
by a relaxation of the broad and round ligaments 
above ; second, by a want of due tone in the vagina 
below. By the first, the uterus is permitted to fall, 
and by the second, the uterus is allowed to be received 
into the cavity. Such being the state of the parts, it 
is clear that a very slight downward forcing will 
depress the womb, and ultimately exclude it from the 
vaginal orifice. This force will be supplied by the 
increased weight of the uterus, if the patient sit up or 
walk soon after delivery or abortion." What value 
then can we attach to this flimsy vaginal support ? 
None. Is it not the chimera of a vacuum plenum brain ? 



152 DISPLACEMENT OF THE WOMB. 

But what medical man can read such anti-chirurgical 
and anti-physiological nonsense without feeling ashamed 
of his cloth. 

Furthermore, if the antagonistical point against the 
action of the diaphragm is made up by the levators, 
the sphincters, the vagina, and theother muscles forming 
the perineal floor below, it is equally clear there would 
not be one displacement where there are now one 
hundred, if it were not for the superincumbent weight 
of the viscera of the abdomen and the force of the 
diaphragm. The diseases of the organs contained in 
the cavity of the pelvis, are so closely connected, that 
the displacement of any one deranges the others. 
The uterus being displaced, frequently compresses the 
rectum and bladder. The rectum, overloaded and 
distended, deranges the uterus and vagina. Over dis- 
tension of the bladder displaces the uterus, and pro- 
duces prolapsus of the vagina, which is one of the 
fruitful causes of leucorrhcea. Prolapsus uteri may 
consequently be considered the most frequent, as well 
as the most troublesome disease to which the female 
is liable. 

Dysmenorrhea, the next in order, is a disease ex- 
tremely harassing, and depending upon like causes. — 
During the menstrual period of life, this derangement 
in the functions of the uterus, is the principal cause of 
the sterility that most generally afflicts those who are 
possessed of an irritable lymphatic temperament. 
From close attention to the history of each case treated 
by me, in the last five years, the following is the view 
I have taken of the pathology, drawn from the symp- 
toms of the disease. These are, a sense of fulness, 
tension, and pain in the pelvis, loins, and back, with 



DISPLACEMENT OF THE WOMB. 153 

an accelerated, quick and tense pulse, a hot and flushed 
skin, a strong manifestation of inordinate excitement, 
and congestion of the uterine system. In certain 
cases the febrile symptoms are less violent, owing to 
peculiarity of constitution, or impaired general health. 
Hence it is to be inferred that the organ is first de- 
pressed on the vagina, either directly or indirectly. 
This, too, arises when the functional derangement has 
been produced from cold, giving rise to an increased 
fulness of the organ, and a consequent tendency to 
sink into the vagina. This is the indirect form of the 
disease, but the more direct causes may be traced to 
the superincumbent weight and force, acting from 
above. The organ being thus displaced, its surface is 
brought in contact with new parts, which act on it as 
a foreign body, establishing in its tissues a degree of 
irritation, which invites a greater afflux of blood to the 
parts, and which is much increased at each catame- 
nial period, amounting often to a sub-inflammatory 
action. 

Thus, it seems to me, that the controversy between 
various writers, on inflammatory and non-inflamma- 
tory action, is only reconcilable on the following 
grounds. At the time of the periodical flow, the womb, 
or its lining membrane, is under the influence of inflam- 
matory action, and, during the interval, it is in that 
chronic, or sub-acute form, which constitutes the con- 
dition spoken of, as a rheumatic affection. In the 
formation of the pseudo-membranous substance, which 
is often discharged, it is evident that an inflam- 
matory or highly irritable state of the parts must have 
existed previously. — In this, I am sustained by Hunter, 
Mackintosh, and Eberle; and when the menstrual 

14 



154 DISPLACEMENT OF THE WOMB. 

action of the uterus is morbidly deranged, it is suffi- 
ciently obvious that the structure of the organ is in a 
morbid condition in some of its tissues. Hence, with 
a depressed womb, (the os uteri resting upon the 
vaginal floor of the perineum,) the weight of the vis- 
cera of the abdomen resting upon its fundus and liga- 
ments, must necessarily produce retroflexion, or 
anteflexion, and consequently form an angle, or bend in 
its cervix. While the entire organ is thus resting 
against new parts, acting upon them as a foreign 
body, what cause or causes are better calculated to 
produce dysmenorrhea ? 

But by this suggestion it is not to be understood 
that they are the only causes of the disease. Some 
cases, though few, are congenital, and others may 
have been the result of a morbid action. In patholo- 
gical anatomy it is understood as a principle that when 
"a mucous canal comes to be traversed by a less 
quantity of the fluids to which it gives passage, it 
undergoes more or less considerable contraction ; 
on the contrary, however, when the fluids are more 
abundant than usual, the mucous membrane becomes 
much dilated, and recovers, though slowly, its primary 
dimensions after the cause of its distension ceases to 
act." The former of these pathological changes may 
account for Dr. Mackintosh's cases treated by dilata- 
tion ; the latter should admonish us to use no remedy 
that would produce fluor albus. In my practice I have 
found nineteen cases out of twenty of my patients 
laboring under dysmenorrhea, and the uterus too low 
in the pelvic cavity, and have invariably removed this 
irritating cause by the application of the supporter, 
with such other remedies as the pathology of the 



DISPLACEMENT OP THE WOMB. 155 

cases required. In this position I am sustained by 
Professor Meigs himself, who says, "a womb that is 
maintained at its proper height, and in its proper atti- 
tude in the pelvis, will be, ceteris paribus, less likely to 
be the subject of dysmenorrhea." He also, in a second 
sober thought, appears to have discovered the secret 
of misplacement, and says, " that the os tincse rested 
upon the floor of the pelvis, where it had long rested ; 
and I supposed that the weight of the uterus and the 
superincumbent pressure had produced an anteflexion 
of the cervix." That dysmenorrhcea should have con- 
tinued so intractable, and the action of remedies so 
very unsatisfactory, is not to be wondered at, since the 
cause is constantly in action. The uterus is com- 
posed of a dense fibrous substance, covered externally 
by the peritoneum, and lined by a mucous mem- 
brane, which is continuous from the vagina, through- 
oat the entire organ, into the fallopian tubes ; — 
along which it extends to their fimbriated extremities, 
where it becomes continuous with the peritoneum — 
thus, presenting a singular example of the continuity 
of a mucous and serous membrane, with each other. 
To this anatomical arrangement, and known physio- 
logical law of the tissues, is to be attributed the failure 
of the pessaries in prolapsus. — Yet the author of 
"Females and their Diseases," even in this enlightened 
age, recommends them to his students, and says, " that 
only weak people and quacks pretend to scorn them." 
But, in the next page, I suppose, after having con- 
sidered the pathological condition of the parts, and the 
modus operandi of the instrument, he says, " I detest 
the pessary as a disagreeable and disgusting thing, 
whether to order or to wear. — I will never employ one 



156 DISPLACEMENT OF THE WOMB. 

except where a conscientious regard to the sanctity of 
the interests committed to my care seems to render it 
indispensable." 

Burns, however, in speaking of dysmenorrhea, says, 
" this state of the womb sometimes produces, besides 
uterine pain, spasmodic affection of the bowels, or vio- 
lent bearing down efforts of the abdominal muscles, as 
if it were intended to expel the womb itself. Such 
efforts are also sometimes made periodically, when the 
menses are altogether or nearly obstructed." Which 
very clearly shows the necessity of some kind of ban- 
dage or support, to overcome the spasmodic affection 
of the abdomen. 

The cure of these displacements — Prolapsus, Proci- 
dentia, Retroversion and Anteversion — consists in 
removing the cause, or causes, and in making an arti- 
ficial support to resist the weight and pressure from 
above. This is accomplished by the application of 
pressure at the exact point where it is wanted. Then 
!>y the administration of the appropriate medicines, 
according to the symptoms of the disease, by the use 
of moderate exercise in the open air, and by sponging 
the body with cold water in the morning, when not 
counter-indicated by organic disease; when it is, 
wash with warm whiskey and water, or salt and water. 
Where the disease is produced by child-bearing, fric- 
tion may be resorted to. 

Having thus considered all that is necessary in 
relation to the arguments of the learned Professor, it 
only remains to recapitulate the views I entertain 
upon the subject. — In the human economy, it is well 
known, that the various organs are so arranged, as to 
be subservient to each other, — that each by the 



DISPLACEMENT OF THE WOMB. 157 

arrangement of the elements of which it is composed, 
is possessed of organic life, and by the harmonious 
action of the whole, animal life is attained, health is 
secured, and each organ within the economy is enabled 
to perform its specific function. When a failure takes 
place in any of the organs, we know it must result 
from some definite cause or causes ; but whether they 
are chemical or mechanical, it is certain that a 
removal of the cause is necessary before the cure can 
be effected. I, therefore, contend — 

" First. That the uterus is sustained by its liga- 
ments, and not by the vagina. 

Second. That the round ligaments are not the only 
support that prevents the uterus from being retro- 
verted ; but that portion of the peritoneum which 
overhangs those ligaments and the utero-vesical sep- 
tum, are the chief reflections that prevent retrover- 
sion. 

Third. That the uterus must first be elevated and 
somewhat enlarged before it can be retroverted, or its 
fundus must be forced below the promontory of the 
sacrum before retroversion can take place. 

Fourth. That prolapsus, procidentia, retroversion, 
anteversion and flexions of the uterus, are owing to a 
relaxed or weakened condition of the ligaments of 
the uterus, and the superincumbent weight of the 
viscera and force of the diaphragm. 

Fifth. It seems to me, that this writer, upon 
" Females and their Diseases," resulting from mis- 
placements of the womb, has lost sight of one of the 
most important elements in the pathology of those 
cases — and that is the state of the ligaments which 

14* 



158 DISPLACEMENT OF THE WOMB. 

are attached to, and within the pelvis, which support 
the womb. 

He ought to have observed and remarked upon this 
important physiological law, viz : that the diaphragm 
has an antagonistical force on the floor which is 
formed at the upper marginal brim of the true pelvic 
cavity, and where this floor retains, together with the 
muscular parietes of the abdomen, its full power and 
energy, there can be no displacement of the womb. 
The repeated distension of the muscles of the abdo- 
men, during the term of gestation, and the debilitating 
causes attendant on constipation of the bowels, with 
their frequent over distension with gas, cannot but tend 
to debilitate those parts, and overcome their pow r ers of 
resisting the bearing down force of the diaphragm ; — 
and as the womb depends for its support on the firm- 
ness of the tissues composing its ligaments, it is clear 
to my mind, that it will be carried down by the loss of 
power in the one and the force of the other. Hence, 
it is evident, both by reasoning upon, and by observing 
clinically, the facts, in the displacements of that organ, 
that the weakness and loss of power of the muscles 
of the abdomen, and the ligaments of the womb, have 
much to do with the pathology of those displacements 
of the uterus. 

Sixth. " That long continued tenesmus, connected 
in its origin with a costive condition of the rectum," and 
which the author asserts produces shortening of the 
vagina, I regard as the cause which calls into action 
that powerful muscle, the diaphragm, and produces 
displacement of the organ. 

The principles which have governed my conduct in 



DISPLACEMENT OF THE WOMB. 159 

my intercourse with the medical profession of my 
country are so well known that it is unnecessary to 
give them in detail. Suffice it to say, I lay no claims 
to superiority, nor urge empirical pretensions to their 
notice, but with that liberality which becomes the 
votaries of our science, would commend to their care- 
ful attention those principles of Truth which have 
been gained by a life of Professional toil, in " Prac- 
tical Anatomy" and in " Clinical Medicine." 



ASIATIC CHOLEEA. 



Having alluded to this fatal epidemic in the pre- 
ceding essay, it becomes necessary, in the way of 
illustration of my views, to make further remarks 
in relation to the treatment and character of the 
malady ; with the additional remedial agents which I 
deem requisite to meet the indications. The approach- 
ing signs of this epidemic are generally a deranged 
condition of the secretions, manifested by a disturbed 
condition of the stomach and bowels, with giddiness, 
debility, lassitude, a sensation of heat and distension of 
the stomach, nausea and vomitings. Also diarrhoea, 
cramp of the extremities, and in some cases spasms 
extending to the entire muscular system, with profuse 
perspiration. At first, the discharges from the 
bowels are but little changed in their natural charac- 
ter. After the first passage, they assume an ash color, 
or whitish appearance. These premonitory symp- 
toms are not always the same in degree, being 
slight in some and severe in others; their dura- 
tion is also irregular. In many the disease appears 
without premonition, and in some the characteristic 
symptoms are wanting; but such cases are rare, and 
the greater number, after diarrhoea has continued a 



CHOLERA. 



161 



few days, are attacked with the full force of the disease. 
In some, the stomach is but little affected, while not a 
few are affected with cramp. The most prevalent symp- 
toms are, the profuse perspiration, diarrhoea and intol- 
erable thirst, uniform attendants in most cases, with 
extreme restlessness, and livid, contracted appearance 
of the extremities and face. This singular epidemic 
generally disappeared under the same symptoms with 
which it commenced, and when at its full height, it 
would suddenly change and pass off. 

It is generally divided into three stages, and 
arranged agreeably to the conception of its character. 
The first is the forming stage of congestion; the 
second, complete congestion of the two tegumentary 
systems, and capillaries throughout the economy; and 
the third stage is that of reaction. 

The first stage is delusive, and cannot be regarded 
as characteristic of the disease, as many who are 
affected with the premonitory symptoms, have vital 
resistance adequate to maiutain a balance of the cir- 
culation, and thereby to resist the force of the offend- 
ing cause. But when the disease attacks those 
already debilitated by any antecedent cause, they are 
apt to fall an early prey to the effects produced by the 
morbific agent. 

In the second stage, no one can be deceived by the 
symptoms; the discharges from the stomach and 
bowels are glary white. There is a complete suppres- 
sion of the secretions of bile and urine, with almost 
an entire failure in the functions of the heart and 
arteries, while the body is covered with cold clammy 
sweat. These symptoms in connection with the cold- 
ness of the surface, the livid and corrugated appear- 



162 CHOLERA. 

ance of the extremities, cannot be misunderstood, as 
the full stage of congestion constitutes the second 
stage of the disease. 

The third stage restores the animal heat, and 
not unfrequently fatal inflammation ensues from 
violent reaction; but this is the hopeful stage of 
recovery, and the desirable one, be the sequel what it 
may. 

The post mortem appearances vary according to 
the stage in which the patient died. When carried 
off in the cold congestive stage, the external appear- 
ance diners but little from the blue and contracted 
appearance of the hands and face, previous to death 
— the eyes are depressed in their sockets, the muscles 
rigid and contracted. On opening the abdomen, if the 
disease had run a rapid course, the peritoneal mem- 
brane has a dry appearance, or rather a want of its 
usual glossy polish, from being deprived of its lubri- 
cating fluid. The membrane itself has its usual color. 
On opening the stomach and bowels, a similar fluid to 
that thrown off' before death is found within them. 
The inner coat is injected and more highly colored 
than is natural, with flakes of gelatinous substances 
attached, or hanging loosely to the inner surface. 
The bladder is unusually contracted — the liver but 
little altered, the spleen diminished, the lungs, brain, 
heart, but little altered, if any. In fact, in those cases 
where the course has been rapid, the organs contained in 
the cranium, chest and abdomen, really have no organic 
lesions, and there is nothing to account for the hurried 
death, except the extreme congestion of the capillary 
vessels. The arterial system is generally empty, or 
nearly so. In the subjects examined in which the 



CHOLERA, 



163 



system had reacted several days previous to death, the 
appearances of the fluids in the stomach and bowels 
were altered, and various organs throughout the sys- 
tem were marked to a greater or less extent, with 
inflammation and its consequences. But on this 
subject details are left to other authors. 

The appearances before and after death, are so 
uniform, that most writers have concurred in their 
remarks as to the extreme congestion. But it is obvi- 
ous to me that a misapprehension exists with some 
who have written on the subject; who, from the quan- 
tity of blood found in the large venous trunks and 
right side of the heart, infer that congestion here is 
one of the causes of death. But the truth is, accu- 
mulations could not have thus taken place except in 
the act of dying and after death, in consequence of 
the contractility which forces the blood from the 
capillary vessels, and onward in the venous radicals. 
This being a point of practical importance, it is worthy 
the strictest attention; and as we find in the history 
of cholera, a concurrence in the weakened action of 
the heart and arteries, with rapid diminution of their 
size, and a like rapid advance of "ice-like cold- 
ness," we may ask, from what do these symptoms 
proceed, if not from a semi-stagnation of the blood in 
the capillary vessels ? 

We know that a full circulation gives heat and size 
to the arteries; but, in this fatal epidemic, the heat 
is diminished, in proportion to the diminution in quan- 
tity of the vital fluid returned to the heart to be re- 
propelled to the entire economy. — We also find that 
the heart continues to perform its functions, in a feeble 
manner, until the fluid is so far diminished, that there 



164 CHOLERA. 

is not a sufficient amount returned to it to induce its 
incitation, and hence death is the consequence of the 
loss of power in the capillaries. 

This capillary congestion destroys the contractile 
force inherent in these delicate vessels, which is extra- 
ordinary until overcome by mechanical or chemical 
causes. The functions of these vessels also are de- 
pendent upon the physical force of the contractility, 
which the blood incites, and which is found to con- 
tinue in action for a greater or less time after animal 
life is extinct. Hence, it is manifest that the circulation 
very much depends upon the elasticity and contractility 
of the coats of these vessels, from the well known fact 
that much less blood is found after death in the 
parts which were inflamed previous to death. This 
same force empties the arteries and engorges the 
various trunks by the movement of the fluids, which 
will account, in this disease, for the return of ani- 
mal heat after death. This part of the circulating 
system, appears to have been wisely endowed, as we 
find one set of capillaries furnished with the principles 
of vital contractility sufficient to resist the entrance of 
the red blood, whilst another set are incited to the 
performance of their special functions by its presence. 
And again w T e see that within the range of the vital 
action of these extreme vessels, secretion and nutrition 
are carried on ; and the first signs of disease or of 
returning health, are also displayed at this vital peri- 
phery. Hence the necessity of a high endowment of 
life at this part of the economy. 

In this disease, as death pervades the system, the 
extreme spasms are to a greater or less extent over- 
come ; whilst organic life remains possessed of suffi- 



CHOLERA. 165 

cient force to restore animal heat to the entire body 
from the motion of the circulating fluid impelled by 
the contractility of the capillary vessels, after death ; — 
which accounts for the blood found in the heart and 
venous trunks. For if during life the blood had been 
returned to the heart in such quantities as is found 
after death, though reduced in its vital principles from 
a loss of part of its organic elements, it must be mani- 
fest, that life would have been supported much longer 
in all; and in many cases the system would have 
reacted favorably to recovery. Hence it is evident 
that death is produced in cholera from the failure of 
the physical functions of the capillary vessels, and the 
consequence of exalted action in the functions of the 
two tegumentary systems. The early symptoms of 
the disease most clearly prove this fact, as the size of 
the arteries is diminished from the commencement, 
which diminution rapidly continues until the pulse be- 
comes extinct at the wrists, whilst the accumulations of 
blood are more and more manifest in the extreme ves- 
sels; in many cases these vessels become so much 
distended that their contractility is completely destroyed, 
or at least so much weakened that in cases of incised 
wounds they do not contract with sufficient force to 
propel the fluid from their calibers — yet notwithstand- 
ing the extreme congestion of the capillaries, the sensi- 
bility of the system is but little impaired, as is manifest 
in the suffering of patients from mustard plasters. 
The intellectual faculties are generally sound from the 
commencement of the disease until life is extinct, unless 
where the system reacts and inflammation supervenes. 
Thus from the regularity of the congestion and the 
occurrence of the slight nervous derangement, it is 

15 



166 CHOLERA. 

evident, that the circulating system is the first im- 
pressed by the morbific agent, be that what it may. 

Therefore, from the foregoing conditions, and the 
history of the disease, as given by authors, it is mani- 
fest that, in its treatment mechanical agents are 
required if we expect to remove the congestion, which 
commences in the capillaries from direct impressions 
made upon them and the extreme nerves. For let it 
be remembered, that if the congestion were produced 
trom a weakened action of the heart and arteries, 
diffusible stimulants would have been more successful 
in restoring the lost balance of the circulation. Hence 
this epidemic was more prevalent where the internal 
tegumentary system had been enfeebled or deranged 
by antecedent causes. The fact has been observed 
on every continent, and in every clime or district — 
that in proportion to the strength of the stomach and 
bowels, was the security against the epidemic. But 
the reader will consult the various authors for the his- 
tory, symptoms, and remedial agents recommended 
by the profession ; as it is the object of this essay only 
to introduce some additional remedial agents found 
valuable in practice. 

TREATMENT. 

The treatment of Cholera depends entirely upon 
the stage of congestion and reactions ; as the reme- 
dial agents adequate and proper in one stage of the 
disease, would be inadequate and improper in another. 
Much also is dependent upon the adaptation of the 
remedy, and its conformity to the physiological and 
pathological effects on the economy. The symptoms 
in the forming stage of congestion are, derangement of 



CHOLERA. 167 

the digestive organs, loss of appetite, a sense of ful- 
ness in the epigastrium, heat, colic pains in the bowels, 
diarrhoea and debility. The indications are as fol- 
lows : — 

I. To check the further extension of the congestion 

already commenced. 
II. To correct the secretions, and allay the irrita- 
tion of the mucous membrane of the alimentary 
canal. 
III. To restore the loss of balance in the circulation, 
and remove all causes of internal and external 
irritation. 
These objects in the incipient stage may be readily 
obtained in the following manner : — 

I. By a full suit of flannel to be worn next the skin. 
II. By correcting the secretions of the liver, stomach 
and bowels, by the use of small and repeated 
doses of calomel and opium ; bandages and sup- 
porters, to prevent gravitation of the viscera 
and to assist the capillary vessels in returning 
the blood to the heart. 

III. The irritation, internally, may be corrected by 

the use of laudanum, sulphuric ether, camphor, 
alkalies, and a mild, bland digestible diet, regu- 
lated in accordance with the condition of the 
stomach and bowels. 

IV. The best means for the removal of external irri- 

tating causes, is to keep the patient in bed, with 
warm irons at the feet, permitting only the 
necessary attendants. 
By the use of these remedies, in appropriate doses, 
and the application of the bandage with a strict adhe- 
rence to the rules, as directed, the disease, in a very 



168 CHOLERA. 

large majority of cases, will be checked in its incipient 
stage. But much depends upon the management of re- 
medial agents, to restore and sustain the balance of the 
circulation, and prevent the rapid waste of the vital 
fluid, from the exalted morbid action of the internal 
and external tegumentary systems. 

The remedial agents which I have found most 
efficient in the treatment of this disease in addition to, 
and in conjunction with, such as are usually employed, 
will be more fully described in the treatment of the 
second stage of the disease. Notwithstanding the 
cause of cholera is unknown, its effects are as in- 
delibly marked as a burn, and no more liable to 
be mistaken than the effects of such an accident. 
Hence the fundamental indications are as plain, though 
the remedial agents may not be as successful as those 
resorted to in the treatment of burns. As the treat- 
ment of cholera then, is really the treatment of con- 
gestion and its consequences, it will therefore be safe 
in the hands of the skilful practitioner, who will regu- 
late his remedial agents in accordance with the failures 
of the physical and organic functions. 

The mechanical agents which I have used as ad- 
juncts in cholera, and found efficient in congestive 
fever, and in the collapsed stages of other fevers ; also 
in many cases of cholera morbus and cholera infantum 
since 1833, have fully established their utility. I 
therefore confidently submit them to the profession. 
The cases in which they have failed, had extensive 
organic lesion, from inflammation, so that no course 
of treatment could have succeeded against the secon- 
dary form of congestion. 

Those mechanical agents which I have found abso- 



CHOLERA. 169 

lutely necessary to overcome congestion in cholera, 
and check the profuse waste of the constituents of the 
blood by the morbid action of the skin and mucous 
membrane of the stomach and bowels, are as follows : 
— The common muslin roller for the extremities; a 
flannel roller for the abdomen ; pledgets for the colon ; 
small dry or wet cups on the surface of the body; the 
lancet, gentle friction, aided by elevating the hips for 
a few minutes after the patient has been over the 
close stool. 

The roller is better adapted to meet the indications 
of congestion of the capillaries, as it is evidently owing 
to a loss of power in those vessels, from their engorged 
condition and the tonic spasm of the tissues. Con- 
gestion being the principal cause of the hurried death, 
it is evident it matters not what has produced it, as 
it must be removed, and speedily too, or death will be 
the result. 

The roller, in the second stage of the disease, is the 
most efficient agent in the catalogue of mechanical 
means, when properly applied. In congestion, when 
the surface is cold with evident marks of loss of vita- 
lity in the extreme vessels, it should be commenced 
at the extremities with sufficient force to be gradually 
diminished as it passes to the body, so that the sup- 
port should act equally from the extremities upwards, 
and in proportion to the extent and permanence of 
the congestion should be the tightness of the bandage. 
If the disease has reached the stage of collapse, the 
bandage should be drawn as tjght as the strength of 
the muslin will bear, to force the blood through the 
venous radicals. This roller assists the capillaries to 
perform their functions ; — it is well known in surgery 

15* 



170 CHOLERA. 

to be an efficient agent in overcoming spasmodic con- 
tractions; hence its indication in cholera, to check the 
spasmodic cramps that occur therein. 

This is the more evident when we consider the 
change produced after the spasms cease in death, when 
the heat of the body is restored by the movement of 
the blood in the capillaries. 

Under the flannel roller around the body, when the 
bowels are too freely moved, two wedge-shaped 
pledgets should be applied over the ascending and 
descending colon. The roller should commence at 
the hips with sufficient tightness, gradually dimin- 
ishing in pressure as it passes upward to its termi- 
nation two inches above the umbilicus. The tightness 
of the roller and the size of the pledgets will always 
be varied to meet the emergency of the case. In 
some cases they will be required partially to obstruct 
the ascending colon, and so completely obstruct the 
descending portion, as to check the action of the 
bowels. When properly applied, they afford great 
comfort to the patient from the support given to the 
viscera, and at the same time they abate the spasms, 
thereby permitting the blood to return to the heart. 
Again, by the aid of pledgets the bowels may be so 
controlled that small and repeated doses of calomel 
and opium, which are often indicated, are retained 
within the stomach and bowels, sufficiently long to 
change the secretions, which is so requisite in the 
treatment of this disease. Small cups are frequently 
required to assist in removing the congestion where 
the bandage fails to propel the blood through the 
capillaries. By the use of these on different parts of 
the body and extremities, the motion of the fluids is 



CHOLERA. 171 

facilitated, which should be aided by gentle friction 
made with the hand or any soft materials. If dry 
cups with friction fail, the wet cup should be resorted 
to, which, from the sudden vacuum produced by them 
in the capillaries, and the small amount of blood ex- 
tracted, frequently produces the desired effect. In 
some cases, by the use of the bandage, cups and 
friction, the circulation will be only partially improved, 
and when this occurs in full habits, by the aid of gen- 
eral depletion and the free use of warm brandy we 
may frequently establish full reaction. The quantity 
of blood to be taken, must be determined by the ope- 
rator, as no general rule can be given with any degree 
of safety. Friction is a useful adjuvant in cholera if 
gentle; but if not, it is prejudicial and highly injurious, 
as the object to be derived is not to increase general 
sensibility, but to restore that part of the circulation 
which is depending upon the propelling force, inherent 
in the capillaries, and has been overcome by engorge- 
ment and spasmodic contraction. The severe frictions 
practised in 1833, uniformly injured the patients, as 
they were made with rough materials and with too 
much force. In paralysis, such force may be admis- 
sible, but not in cholera. I have known dyspeptics to 
perpetuate the morbid action of the stomach and 
bowels by the use of the hair glove, which only excited 
the surface and cutaneous vessels, at the expense of 
the natural pores of the skin. Then let it be remem- 
bered, that friction in cholera, is designed to assist the 
enfeebled vessels in moving the fluid contained in their 
callibers, and not as a rubefacient. 

Elixir of vitriol is one of the important remedial 
agents required in the treatment of cholera, from its 



172 CHOLERA. 

prompt action in abating thirst and moderating the 
morbid cutaneous, and intestinal secretions, which 
throw off part of the constituent elements of the 
blood, and which if not checked, leads to serious conse- 
quences. The various tests made with the different 
acids in 1833, and since that time in cholera morbus 
and congestive fevers, decidedly give elixir of vitriol 
the superiority. The usual dose when the sweats are 
profuse, is ten minims, diluted in half a glass of cold 
gum water, and given every fifteen or twenty minutes 
until the thirst and sweats are abated ; about one 
drachm will generally suffice to check these, and quiet 
the stomach; when it is thrown up, it should be 
repeated every five or ten minutes in smaller doses. 
It should be taken through a quill to prevent injurious 
effects upon the teeth. 

When the roller and pledgets are not required for 
the abdomen, the patient should be directed to elevate 
the hips for a few minutes after each alvine evacu- 
ation. 

By the use of the roller, pledgets, supporters, dry 
and wet cups, elixir of vitriol, and the necessary pre- 
caution in elevating the hips, with the judicious use of 
other approved remedial agents, this fatal epidemic 
will be controlled and cured with nearly the same suc- 
cess as any of the diseases produced from malaria. But 
cholera being the most violent order of congestion, 
the deaths after reaction, in this disease, must be 
greater than from congestive or yellow fever. 

The third stage of cholera, is that after the system 
has reacted, developing fever, and not unfrequently 
inflammation, to a greater or less extent throughout 
the system ; but more especially upon the brain and 



CHOLERA. 



173 



organs of the abdomen, which should be treated by 
leeching, rubefacients to the extremities and cold water 
to the head. When the violence of the fever restores 
the arteries to their natural size, wet sheets will be found 
to act as efficiently as in ordinary continued or remitting 
fevers. But if delirium or coma be present, and the arte- 
ries contracted, ice- water should be poured on the head, 
the body wrapped in a sheet wet with warm water, and 
mustard plasters applied to the lower extremities. By 
this course the blood will be diverted from the brain 
and the system brought into that condition in which 
the treatment recommended in remittent fever will be 
indicated. During convalescence, as relapses are fre- 
quent and easily produced, the diet should be mode- 
rate in quantity and quality, mild and digestible. 



ECHANICAL AGENTS 



In noticing the mechanical agents used by surgeons 
and physicians, it is not my intention to give their 
history, their mode of application, or the object for 
which they were constructed, but to describe the 
advantages I have derived in practice, from some of 
them, and the qualities of others I have been obliged 
to construct. I have found the bandage, or roller 
exceedingly useful, not only in the maladies that are 
termed accidental, but in the variety of ulcers, varicose 
veins, tumors, inflammations, cedematous swellings, 
debility, spasm of the muscles, &c. &c. In some 
cases it is used as a defence, in others as a sup- 
port to retain the parts in apposition, and in many, as 
a stimulant to restore the lost power of the absorbents, 
or to exalt their action in effusions, swelling of the 
joints, contusions, fractures, dislocations, amputations, 
with fungous growth of ulcers. 

In the hands of the accoucheur, we find the band- 
age is used for lying-in women, and occasionally 
during the term of gestation. But from the experi- 
ence of ages, as well as the evidence derived from 
practice, we have a right to regard it when properly 



MECHANICAL AGENTS. 175 

applied, as efficient in the alleviation or cure of disease, 
as any other of our remedial agents. But many of 
the various contrivances that are thrown upon the 
profession, in the shape of bandages, suspensory braces, 
splints and trusses, are entirely deficient in their 
mechanical arrangement ; while others called improve- 
ments by the factors, have lost by change of form, 
whatever of fitness or adaptation they formerly pos- 
sessed, and of course their efficiency in the cure of 
the diseases for which they were intended. Of the 
number, however, that have resisted the ravages of 
time and the several encroachments of the venders, 
is the roller, which being simple and easy of construc- 
tion only requires proper adjustment to insure the 
desired effect. In acute or sub-acute inflammation, 
by giving support to the enfeebled vessels, it checks 
the disease and frequently subdues it entirely. In 
dropsical swellings, when acute inflammation super- 
venes in the extremities, it prevents mortification, and 
often saves the life of the sufferer; as soon as the 
inflammatory action subsides if the constitution be 
not seriously impaired, the bandage acts as a stimulant 
to the enfeebled absorbents, and readily diminishes 
morbid action. In fractures and disclocations, it acts 
as an antiphlogistic, by diminishing or preventing the 
determination of blood to the part, thereby accele- 
rating the functions of the absorbents. 

The double roller, if properly applied in some frac- 
tures of the extremities, will be found to supersede the 
necessity of splints and also of extension and counter- 
extension, as they relax the muscles by compression. 
In indolent ulcers the roller is equally effective, where 



176 MECHANICAL AGENTS. 

there is fungous flesh, for it restores the harmony of the 
part, which is all that is required in attaining the cure. 
In cholera infantum or summer complaint the roller is 
useful, especially if assisted by wedge-shaped pledgets, 
which should be placed over the ascending and de- 
scending colon with their base in the iliac fossa, and 
extended from the lower boundary to two inches above 
a transverse line drawn through the umbilicus. When 
the evacuations are not too frequent, but colliquated, 
the roller will be sufficient without the pledgets. In 
such cases, it not only gives the necessary support, 
but moderates the increased peristaltic movements of 
the bowels, with as much certainty as it overcomes 
the respiratory movements in fractures of the ribs. In 
all cases where the bowels are laboring under inflam- 
mation, whether in summer complaint, diarrhoea, fever, 
or enteritis, a roller, (with two pledgets of sufficient 
size to fill up the inguinal regions from the pubis to 
the anterior superior spinous process of the ilium,) 
passing around the hips, so as to make the greatest 
pressure below, gradually diminishing it above, will 
more than equal the remedies usually employed. It 
is of service in any form of inflammation of the mucous 
coat of the bowels, and may be aided in its action by 
elevating the hips (with the thighs flexed) of the patient 
for ten minutes after each alvine evacuation, to restore 
the bowels to their natural position, if perchance they 
should be misplaced, as they are in almost all cases of 
debility. 

The roller, then, with proper guards to prevent the 
descent of the bowels, is unsurpassed by therapeutical 
agents. 



I 



MECHANICAL AGENTS. 177 

When the fever is high the roller should- be wet with 
dilated whiskey, emollients are often useful, and some- 
times turpentine is of great advantage. 

The abdominal roller should be made of flannel and 
applied by the physician, as nurses are apt to draw it 
too tight at the upper boundary. 

The Abdominal Supporter, an invention of my own, 
which I have found superior to all others, is so con- 
structed that the bladder escapes the pressure of the 
instrument, and by the arrangement and construction 
of the elliptical pads, with the peculiar form of the 
spring, the back pads and side straps, is well adapted 
to sustain the weight of the viscera and prevent the 
descent of the bowels. In the treatment of inflamma- 
tion of the mucous coat, arising from fever, constipa- 
tion, diarrhoea, dyspepsia, and chronic gastritis, this 
instrument is one of the most efficient agents that has 
yet been tested by the profession. In all the varieties 
of inflammation, except peritoneal or inflammation of 
the uterus, where the bowels have become distended, 
and the tonicity of the muscular coat debilitated, so 
as to prevent them from adapting themselves to 
their contents, it gives almost immediate relief; but 
in the cases excepted, it requires the use of the roller 
and the aid of the remedies recommended under the 
head of constipation. This peculiar bandage is, in 
every part, constructed to correspond exactly to tfte 
anatomical arrangement of the parts, and being unlike 
any other instrument of the kind in use, it is believed 
that, unlike every other, it will completely answer the 
purpose for which it is constructed. Those heretofore 
employed are called utero-abdominal supporters, and 
since the first, constructed by Hull, no improvement 

16 



178 MECHANICAL AGENTS. 

has been made. The solid front, pressing upon the 
urinary organs, entirely destroys their efficiency, and 
makes them better calculated to produce the disease 
than cure it. Those constructed of linen and whale- 
bone are alike defective in their mechanical arrange- 
ment. Their want of adaptation to the inguinal 
region, necessarily causes pressure to be applied where 
it should not be, which renders them in certain stages 
of the disease, instruments of torture rather than of 
cure. As the small intestines are so fixed to the spine 
by the mesenteric attachments with the meso-colon as 
to prevent their falling at their centre to any consider- 
able extent, it is evident that the pressure of the sup- 
porter should be applied to the inguinal regions, in 
order to check the descent of the lateral portions of 
the intestines, which are loose, and subject to gravi- 
tation. 

This will be understood by inspecting the false 
pelvis, and the promontory of the sacrum, with the 
flared condition of the ossa ilia, which was intended as 
a floor for the intestines ; and, by looking at the spinal 
column and the axis of the body, it will be seen that 
a supporter intended to keep the bowels within their 
destined limits, must act in conformity with the elastic 
movements of the parietes of the abdomen. The 
action, from inspiration at this point, being obliquely 
outward and downward, while that from expiration is 
obliquely upward and backward, and the two fixed 
points of these muscles being at the upper and lower 
boundaries of the cavity, it is plain that a bandage or 
spring applied here should act with the greatest force 
at the lower boundary, with a gradual diminution as 
it ascends upwards. It will also be observed, from 



MECHANICAL AGENTS, 



179 



the location of the urinary organs, and from the offices 
they are destined to perform, that any bandage or 
spring pressing upon them must injure the patient. 
The flared condition of the ossa ilia, with the portion 
of the intestines that are liable to descend in a line 
with the venters of the hip bones, makes it clear, that 
all bandages, supporters, pads or pledgets, must be so 
placed or constructed, that their force, when applied 
to the inguinal regions, shall act from the linea alba 
obliquely outwards, upwards and backwards, so as to 
check the descent of the intestines and keep them in 
their natural resting place, the venters of the ilium. 

These facts I have duly considered, and after many 
trials, and a variety of experiments, have succeeded in 
placing before the profession an instrument that has 
proved efficient not only in my own practice, but in the 
hands of some of the most eminent physicians of the 
country. Its spring is circular, corresponding with 
the shape of the hip bones, and terminates in back- 
pads, resting upon the costa of the ilium, where it is 
assisted by elastic side straps, passing from the back 
to the front, and by which the wearer is enabled to 




180 MECHANICAL AGENTS. 

adjust the pressure. The space between the front 
pads with their peculiar formation, is intended to 
relieve the urinary organs. The preceding cut will 
however give a better idea of its appearance ; which 
being different in construction, different in shape, and 
different in action from any other ; I have no doubt 
both the physician and the wearer will find it different 
in its results. 

From great relaxation in the muscular walls of the 
abdomen, occasionally met with in practice, and the 
displacement of the viscera, I have been obliged, in 
some cases, to construct an additional support in the 
shape of a suspensory jacket, not as large as the 
one recommended by Dr. Dewees. This instrument, 
or rather addition to the supporter, is attached to the 
upper margin of the front pads, and by elastic straps 
to a shoulder brace, which is also a different contri- 
vance from any thing in use, and may be worn sepa- 
rately, or attached, as the condition of the patient may 
require. The great object of these additions is, first, 
to meet the condition of corpulent cases, with a pen- 
dulous abdomen ; secondly, where the viscera have 
been permitted to remain in a gravitated condition, 
which, with their influence upon the diaphragm, carry 
the spine forward and the shoulders inward and for- 
ward, which, after continuing for a time in this posi- 
tion, (although the viscera may be restored,) require 
assistance to enable them to return to their primitive 
attitude. 

This is effectually afforded by the united use of the 
instruments, and by occasionally elevating the hips 
and flexing the thighs a few minutes. 

In colic, a complete inversion of the body will be 



MECHANICAL AGENTS. 181 

required to restore the bowels to their proper posi- 
tion; in chronic uterine displacement also, the same 
treatment will restore the organ to its proper eleva- 
tion, where it may be sustained if the viscera be pre- 
vented from resting on it and the lateral ligaments, 
(by the use of the supporter and bandage,) with proper 
care and rest in the recumbent posture, for a short 
time. 

Cupping glasses are very important mechanical 
agents. 

In the treatment of capillary congestion, the small 
cups, (half the usual size,) applied on various parts of 
the body, have proved very efficient, when aided by 
friction and the use of the common roller. These 
means have saved many from an untimely grave. 

In typhus or typhoid fever where the pulse was 
almost imperceptible, when the morbid inflammatory 
action on the internal organs had been partially 
relieved, I have seen the happiest results from the use 
of these agents. 

In irritative fever also, where there is watchfulness 
and a thready pulse, the same success has followed, 
(the roller being applied to the extremities,) the pulse 
has increased to nearly its natural size, and diminished 
in frequency from one hundred and thirty to eighty, 
while sleep was obtained, and diaphoresis established. 

These agents alone cannot overcome local inflam- 
mation, so as to produce such a change, nor should 
we expect it; but, from the intimacy between the 
capillary vessels of the external and internal surfaces, 
they will greatly assist in bringing the morbid action 
under the control of the ordinary remedies. How 
many cases do we meet with, where no organic 

16* 



182 MECHANICAL AGENTS. 

changes are to be found after death, that will satis- 
factorily account for the fatal termination ? Is it not 
more than probable then, from the tendency of the 
fluids to gravitate, and from the loss of power in 
the capillary vessels, that the heart propels the red 
blood into the capillaries, where it gradually accumu- 
lates until the amount of blood in circulation is insuf- 
ficient to support life. The condition of the capillaries 
after death, strongly inculcates this doctrine, for we 
invariably find in post mortem examinations, that the 
capillaries of the most pendant parts, are congested 
or engorged with purple fluid, if death has ensued 
from debilitating disease ; but such congestion, is not 
seen when death is sudden, as from disease of the 
heart, asphyxia by hanging, &c. I have tried in vain 
to find it in five cases, in which death resulted from 
strangulation. 

Such results prove conclusively, to my mind, that 
this capillary congestion, is not the effect or result of 
death, but rather the cause of death. 

The Pessary, as a mechanical agent, has been 
employed in every age and country, and generally with- 
out credit to the profession or relief to the afflicted. 
At the present time, notwithstanding this fact a 
difference of opinion exists, which to me is strange 
indeed, since the anatomy of the parts, their patholo- 
gical condition, and the mechanical action of the 
pessary, present insurmountable objections to its use. 

Is it not time to discard such unnatural, indelicate, 
health-destroying remedies, and practice in accord- 
ance with the laws of the animal economy and the 
legitimate action of the remedial agents ? A stubborn 
adherence to obsolete, vulgar, and antiquated remedies, 



MECHANICAL AGENTS. 183 

is not an evidence of the march of intellect, or general 
improvement in science. It is pacing upon the old in- 
clined wheel, and perpetuating the notions of antiquity, 
that have tortured the better portion of creation since 
the date of the invention. As a remedial agent, it has 
not been successful in one case out of fifty, and is not 
admissible in any case of prolapsus, procidentia, or 
retroversion, resulting from ordinary causes, except 
where laceration of the perinseum exists, and then but 
as the lesser of two great evils. All other misplace- 
ments of the womb are best treated by removing the 
causes of derangement, and by giving nature that 
support which is necessary to recuperative action. 

If a pessary be used as an adjuvant to the exter- 
nal supporter, it should be constructed (very differ- 
ently from those in general use,) of India rubber, in 
the form of an oblong sack, of thin material, to render 
it yielding, lest it might irritate and produce absorp- 
tion, excoriations, &c. This should be furnished with 
a ligature by which it should be extracted every two 
or three days for the purpose of cleansing the instru- 
ment, and washing the parts. It should not be con- 
tinued in use more than two weeks at furthest. 

But I may express my views as well while I quote 
the language of a celebrated author, Dr. Whitehead, 
surgeon to the Lying-in hospital at Manchester; who 
has recently published an elaborate work, on "Abor- 
tion and Sterility." Having examined some two 
thousand cases, from which it may be presumed his 
acquaintance with the effects of such remedial agents 
was somewhat familiar, he says; "The treatment 
generally adopted in these cases, (prolapsus uteri, &c.,) 
is altogether unscientific and ineffectual ; consisting, 



184 MECHANICAL AGENTS. 

principally, in the application of mechanical support 
by means of pessaries, a great variety of which have 
been, at different times, invented for the purpose. 
These instruments serve, generally speaking, to main- 
tain the displaced organ in an elevated, although by 
no means in its natural position ; but their pressure in 
the vagina, is one of the most unfortunate and annoy- 
ing circumstances that can possibly be necessitated in 
married life. They invariably aggravate the disease, 
for the relief of which they are employed; they 
extend the inflammatory action of the cervix in cases 
where it was already present, and frequently create it 
in those wherein it did not previously exist; they irri- 
tate, and often completely destroy the healthy tone of 
the vagina, augmenting the leucorrhceal discharge, 
and, unless very frequently removed, are liable to 
detain the morbid secretion for an indefinite period 
within the cavity; they have also a tendency to 
encourage putrefaction, and thus to originate a source 
of constitutional irritation sufficient to derange the 
general health in a most serious manner." 

Hernia is an affection for the relief and cure of 
which, mechanical agents chiefly, are employed and 
indicated. 

Of these a vast number have been employed, and 
the great variety of forms and modifications which 
have been invented, and which have come into and 
gone out of vogue, and especially their failure to 
meet the indications, prove conclusively, that all those 
heretofore employed have been defective and not well 
adapted to the anatomical arrangement of the parts 
to be sustained. 
v Hernia being a prolific source of affliction to the 



MECHANICAL AGENTS. 185 

human family, with sometimes fearful consequences, 
has given rise to the construction of a vast number 
of bandages, with and without springs, for its relief 
and cure, and to give a history of which could in no 
ways benefit the profession, or afford relief to the 
sufferer. Their forms are generally known, though 
every year has produced its various modifications, 
all of which have proved of little consequence. The 
mechanical arrangement of the blocks or cushions 
employed with a design to close the internal abdomi- 
nal ring, and press upon the external ring, are not 
constructed in conformity with a proper adaptation to 
the anatomical arrangement of the parts, and there- 
fore are not calculated to fulfil the indications; and 
hence the class of hernia that is really curable is 
rendered incurable by such agents. 

Instead of making pressure over two thirds of the 
whole abdominal canal, and thereby leaving the inter- 
nal ring to nature's influence, their force distends 
the internal ring, which being removed admits the 

O 7 O 

entrance of the viscera, and hence a favorable result, 
would be accidental rather than from any judicious 
arrangement of the pads. 

From the anatomy of the parts it is obvious, that 
any substance applied opposite the internal ring is 
compelled to distend it, instead of closing it; the pres- 
sure from a flat or convex surface, with the force of 
the spring acting upon the walls of the abdomen, 
which are made up of yielding or elastic fibres, must 
necessarily increase the internal surface and extend 
the orifice by which the viscera passes into the 
canal. Again: the size of the block is such, that their 



186 



MECHANICAL AGENTS. 



pressure on the parts, obstructs to a certain extent, 
the circulation of the blood, and the action of the spring- 
on the spine produces in some constitutions, serious 
spinal irritation. Other objections might be urged, but 
it is not necessary. Those who have worn them, can 
tell how enduring have been their sufferings. 

Finding these objections to the trusses in use were 
serious obstacles in my practice for the treatment of 
hernia, (especially since those afflicted were obliged 
to resort to their own inventions, for relief,) I com- 
menced to construct an instrument which would if 
possible, answer the desired indications without any 
exceptions, and how far I have succeeded, an inspec- 
tion of its form and proper adaptation to the parts, to 
which it is applied, and also the many happy results 
of its application or employment, will sufficiently 
show. 

The instrument I use for hernia, as may be seen in 
the cut, is similar in its general form to the supporter 
already described ; the pad is so adjusted that it can be 
moved or turned in any direction as the case may 
require, to avoid pressure on the spermatic cord, blood- 




MECHANICAL AGENTS. 187 

vessels, &c» In front is a narrow plate, convex ante- 
riorly, which connects the lateral or inguinal portions 
of the instrument, and by means of which these por- 
tions can be adjusted to the parts at pleasure. 

The inguinal plates to which the pads or blocks 
are attached, have an oblong fissure, and their upper 
boundary acts as an abdominal supporter, whilst the 
lower boundary is so arranged that a lateral and per- 
pendicular play is given to the pads that permits 
their adjustment to the parts where the force is 
required. 

Elastic straps also connect the back pads with the 
front plates, by which the pressure of the pad may be 
increased or diminished, and the pressure of the spring 
on the pelvis prevented. 

To close the internal ring, and at the same time 
give the proper support to the external, will require 
three separate points of action. The triangular 
openings in the tendons of the oblique muscles, 
having two fixed portions of attachment, one at the 
ilium and the other at the symphysis pubis, it is mani- 
fest that a spring being permitted to traverse the inner 
margin of the ilium from the inferior to the superior 
anterior spinous process, and made to act equally on 
the tendinous portion of those oblique muscles at one 
of the fixed points, would make them tense and 
diminish the size of the triangular opening in the ten- 
don, which constitutes the external hernial ring ; and 
at the same time, by this perpendicular pressure at the 
inner margin of the ilia, a degree of resistance is given 
to the entire inguinal region that prevents the parts 
from becoming pendulous, which, if permitted, would 



188 MECHANICAL AGENTS. 

facilitate the entrance of the viscera into the internal 
ring. No instrument acting on one of the inguinal 
regions, by a single spring, fastened with a strap, can 
be properly adjusted to the parts, as the force of the 
pad and neck of the truss are drawn outward against 
the inner and upper junction of the thigh and ilium, 
which compress the inguinal glands and blood-vessels 
of the part. This fact, I have no doubt, has been ob- 
served by every surgeon and physician in Europe and 
America. 

Another point to be observed in the adaptation of 
the instrument is the size of the pads, which should, 
in this variety, be small, and of a triangular shape, 
diminishing in thickness from below upwards, so that 
when applied over the external ring, it will cover only 
half of the abdominal canal, and leave the internal 
ring to overhang the parts opposite the oblong open- 
ing in the inguinal plates. By this arrangement, if 
there be no adhesions of the sac, the internal ring is 
left free, where nature restores it to its normal size. 

Where adhesions have formed to prevent the return 
of the sac, the pad should be increased in width, so 
that when applied to the external ring, it would cover 
two-thirds of the abdominal canal, leaving the inter- 
nal ring free at the upper margin of the pad. 

The different sizes of pads for the several varieties 
of hernia, are noticed under the head of treatment. In 
the treatment of crural hernia, in bad cases, I have 
adapted an additional elliptic spring, to which the pad 
is attached for the purpose of increasing the pressure. 
But the following cut will give a clearer understanding 
of its character. 



MECHANICAL AGENTS, 



189 




For the treatment of diseases of the spine I have 
also constructed an instrument, by which the weight of 
the body is sustained upon the pelvis. This is adjusted 
by means of screws attached to its crutch, and acts 




190 



MECHANICAL AGENTS. 



on the principle of extension and counter-extension, 
straightening the spine and restoring it to its original 
length. The drawing however, I deem sufficient to 
enable the manufacturer to construct it properly. Mr. 
Gemrig, South Eighth street, has made several, to 
order. 

The following drawing exhibits the appearance of a 
shoulder brace, which, in connection with the sup- 
porter, will be found an excellent adjunct in the treat- 
ment of the diseases of the chest, arising from 
gravitation of the viscera of the abdomen, and imper- 
fect respiration. It may be used without the supporter 
by substituting a piece of webbing resembling the old 
suspensary jacket, and fastened by elastic straps at an 




MECHANICAL AGENTS. 191 

angle corresponding with the range of the oblique 
muscle. This is useful for corpulent persons, and 
females during the latter months of gestation ; and in 
all cases of disease arising from strumous habit, and 
loss of muscular power subservient to the support of 
the abdominal viscera and respiratory organs, it is 
indispensable. 

By the timely use of this brace and supporting 
bandage, many of the diseases of the thoracic organs 
will be checked in their incipient stage; and where 
disease of the lungs or the heart has become deve- 
loped, they remove one of the most irritating causes, 
and greatly contribute to the restoration of the patient. 

Every man who understands the anatomical arrange- 
ment of the muscles that are subservient to respira- 
tion, and the viscera of the abdomen, will see how 
impossible it is for debilitated muscles, unassisted, to 
perform their physical functions, and how important is 
the healthy action of the respiratory organs in the 
treatment of disease. He will also see that thera- 
peutical agents are but palliatives, without mechanical 
assistance. 

The elevation of the hips, while the patient is lying 
on his right side, is a very useful means, though tem- 
porary, of restoring the viscera to the cavity of the 
abdomen, w 7 here they compress the diaphragm in 
expiration ; for it not only gives immediate relief to 
the patient, but is a good test in detecting the true 
character of disease. 

By this test, I have found, that many diseases which 
w r ere thought to be affections of the heart, were but 
the result of a depression of the diaphragm from 
gravitation of the abdominal viscera. 



192 HERNIA. 

Reducible Hernia. — The agents used in the treat- 
ment of reducible hernia, in all ages, have been ban- 
dages of various kinds, with or without springs, and 
furnished with pads of soft or solid materials. Each 
kind has had its advocates, and from time to time? 
thejr claims to perfection, have been made and passed 
away. But to the surgeon it must have been obvious? 
that no single form of pad, no matter how well adapted 
for one class, could possibly be adapted to all the 
varieties of hernia. In simple inguinal hernia, where 
the sac has formed no adhesions, the cure must depend 
upon the natural laws of the nutritive deposition and 
contractility of the parts ; but in the other variety, 
where intimate adhesion has taken place, so as to for- 
bid the return of the sac, the cure is to be accomplished 
through adhesive inflammation, excited in the parts. 
In ventral hernia, the cure is to be effected by the same 
process. Professor Gibson, of the University of Penn- 
sylvania, in his valuable treatise on Surgery, says : 

" Reducible, irreducible, and strangulated hernia, 
all require distinct and particular modes of treatment. 

" For reducible hernia, an appropriate truss is the 
only remedy, and the sooner this is applied the better. 
Formerly an opinion prevailed that such instruments 
were not adapted to infants ; the error has been amply 
rectified by modern experience, and much mischief 
thereby prevented. Trusses are either elastic or non- 
elastic ; the latter are now seldom employed, and never 
can be to advantage. A well constructed steel truss 
often effects a perfect cure, especially in children and 
young subjects, by exciting a degree of inflammation 
sufficient to agglutinate the sides of the sac, or the 

Oo 7 

edges of the opening through which the hernia has 



HERNIA. 193 

passed. To accomplish this purpose, great attention 
must be paid by the surgeon in adapting the instru- 
ment to the parts, and by the patient in wearing it 
without intermission. The best mode of fitting a 
patient with a truss, is to try a number of instruments, 
and select the one that adapts itself best to the hollows 
and projections about the abdomen and pelvis, and 
can be worn with the least inconvenience. A well 
contrived truss will fit accurately in every part, and 
set closely to the body, neither bulging in particular 
places, nor binding two closely. Every patient should 
be provided with a spare truss, in case of accident. 
To prevent the pad of the truss from imbibing perspi- 
ration and becoming hard, a bit of calico, muslin, or 
rabbit skin should be placed between it and the 
tumor. With a view also of obviating rust, to which 
the spring is very liable, the instrument may be thickly 
covered with durable leather, or some similar material, 
and with oil-cloth, or gum elastic when the patient 
has occasion to bathe. A truss, to derive full benefit 
from it, must be worn night and day, and for months 
and years together. Particular varieties of truss will 
be noticed when the different species of hernia are 
described." 

In this extract we have all that is necessary by way 
of preface, and as it is presumed every surgeon is, or 
ought to be, acquainted with the anatomy of the parts 
before attempting the application of a truss, I shall 
proceed with the treatment. The numerous and im- 
portant blood-vessels, nerves, and lymphatics found in 
the inguinal region, where hernia prevails, require 
care in the application of a bandage provided with 

17* 



194 HERNIA. 

hard or soft pads, lest too much pressure on the sper- 
matic cord might injure the testes. 

Inguinal and scrotal hernia, where the sac has 
formed no adhesions, and can be returned to the cavity 
of the abdomen, will require a treatment different from 
w r hat is required where adhesions have taken place. 
The same remark applies to the treatment of ventral 
hernia. 

Inguinal Hernia. — The treatment of this species 
of hernia, where the sac has formed no adhesions, 
consists in the application of an appropriate elastic 
truss or apparatus which is calculated, when applied, 
to prevent the viscera of the abdomen from protrud- 
ing, by closing the internal ring, and at the same time 
giving to the external ring, the proper support. The 
inguinal regions being thin and yielding, any pressure 
made opposite an aperture, on an elastic or yielding 
body, will necessarily distend, instead of closing it. 
Hence all forms of pads of a sufficient size to cover 
the entire inguinal canal, and press upon the parts 
opposite the internal ring, check nature in her recu- 
perative powers, in restoring the part to a healtny 
condition : consequently all cases of recovery in this 
species of hernia, have hitherto been the result of acci- 
dent rather than of any judicious arrangement of the 
pads, for these being too large, increase the action of 
the absorbents by their pressure, which gradually 
weakens the parts, enlarges the internal ring, and 
thus lessens the chances of cure. 

In this form of hernia, the size of the pad should 
be sufficient only to cover the external triangular 
opening and one half of the abdominal canal, allow- 
ing the internal ring to overhang its upper margin. An 



HERNIA. 195 

inch and a half above this, the superior boundary or 
rim of the truss which I use, greatly assists, like the 
supporter, the abdominal muscles, in sustaining the 
weight of the viscera, and thus preventing their 
encroachment upon the internal ring. 

The instrument adapted to the treatment of this 
form of hernia, and which I have tested in numerous 
cases for the last fifteen years, is described in the 
essay on mechanical agents, where the reader may 
obtain a better idea of its construction both by the 
cut and description there given. 

In applying the truss, the pad should be placed in a 
position corresponding to the direction of the tendons 
of the oblique muscle and Pouparfs ligament, its lower 
edge resting at the margin of the pubes. 

When applied, the integuments should be raised 
upwards and outwards so that the internal ring will 
be opposite the fenestra, between the pad and rim of 
the truss. 

The patient should be instructed closely to observe 
its proper adjustment, as it is by this that the internal 
ring is closed, and the bowel prevented from escaping. 

Ventro-Inguinal Hernia. — In the treatment of 
this form of hernia, where the sac has formed adhe- 
sions, the pad should be made of wood, or ivory ; 
at least one inch and a quarter in width at the per- 
pendicular line corresponding with the recti-abdo- 
minal muscle, and tapered from its base to its upper 
edge, making it nearly in the form of a right-angled 
triangle. 

A pad of this form and size will retain the bowels 
pressing upon a surface fourteen lines wide over the 
inguinal canal, leaving the internal ring free at the 



196 HERNIA. 

upper margin of the pad, as in inguinal hernia, where 
it rests opposite the opening as above described. This 
is the species of hernia so correctly described by Pro- 
fessor Gibson, as cured by adhesive inflammation, 
excited by pressure upon the sac, or edges of the 
hernia] opening. 

Sir Astley Cooper, whose theory is the same, 
directs that pressure be made upon the internal ring, 
and over the whole inguinal canal, thus exciting inflam- 
mation by which the sac becomes adherent. 

Indeed no plan has been proposed for the cure of 
this affection, which is not based upon the principle of 
union from adhesive inflammation. 

This theory is confirmed by practice in ventro- 
inguinal hernia. But notwithstanding the hernial 
sac is thus readily made to unite, the form and size 
of the pads in general use, distend the internal ring, 
while the absorbents diminish the strength of the parts, 
so that as soon as the pressure is removed, the weight 
of the viscera forces down a new hernial sac, leaving 
the patient worse than before. 

In 1834,1 relied chiefly upon adhesive inflammation 
for my cures, but subsequent experience has taught 
me that but little is gained by the union of the sac, 
unless the internal ring be left free to contract upon 
its neck, which I proved by many experiments. 

In this form of hernia there is a greater liability to 
recurrence, than in that where no adhesions have 
formed previous to the application of the instrument. 
The hard pads, in a majority of cases, should not be 
continued longer than six months, if the bowels have 
been uniformly retained in their natural position. In 
fleshy individuals they may be worn from nine to 



HERNIA, 



197 



twelve months. I have generally found the absorbents 
to weaken the parts and break up new adhesions when 
the pad is worn too long. After the adhesions are 
formed the pad should be changed to one of soft 
materials, of the same size at its lower boundary, but 
diminished in width to the size of the inguinal pads. 
During the use.of these instruments the parts should 
be sponged night and morning with cold water, and 
the hips should be elevated for five or ten minutes 
while in bed, to restore the bowels to their proper 
position. 

Femoral Hernia. — The passage of the intestines 
beneath Poupart's ligament into the crural ring (which 
constitutes this disease) is well described by Professor 
Gibson. 

" The contents of a femoral or crural hernia, instead 
of passing through the abdominal rings, are protruded 
beneath Poupart's ligament through an opening termed 
the crural ring. This ring is bounded on the outer or 
iliac side, by the femoral vein, on the inner or pubic 
side by Gimbernat's ligament, anteriorly by Pou- 
part's ligament, and posteriorly by the pubes. Pou- 
part's ligament arises from the spine of the ilium, and 
is implanted by a broad insertion into the symphysis 
pubis, into the tuberosity of the pubes and into the 
ligament of the pubes, over the linea-ilio pectinea. By 
this last insertion a sharp crescentic edge is formed, the 
concavity of which looks towards the crural vein, and 
is supposed by most writers, to contribute mainly to 
the constricton in cases of strangulated crural hernia. 
From having been particularly described by Gimber- 
nat, a Spanish surgeon, it is frequently called Gimher- 
nafs ligament. There are two margins to Poupart's 



198 HERNIA. 

ligament, an anterior and posterior, the former of 
which is straight, the latter concave, in the vicinity of 
the pubes. 

" The fascia lata of the thigh, as it approaches Pou- 
part's ligament, divides into two portions — the iliac 
(sometimes called sartorial) and pectineal. The former 
is connected to Poupart's ligament throughout the 
greater part of its extent; the latter is attached to the 
pubes, covers the muscles that spring from that bone, 
and unites with the iliac portion below, at the spot 
where the vena saphena major enters the femoral vein. 

" Women are more subject to femoral hernia than 
men, owing partly to the great breadth of the female 
pelvis." 

The instrument used in this form is the same as the 
inguinal truss, and may be easily applied by changing 
the pad from its oblique to a perpendicular direction, 
so that its lower boundary may rest at the upper mar- 
gin of the pubic bone, and in contact with the inferior 
anterior spinous process of the ilium. It will then 
close the crural ring. The pad should not be per- 
mitted to rest fully upon the upper portion of the thigh, 
as it will onlv close the aperture by compressing it 
between the pad and bone, and defeat nature in 
restoring the ring to its natural size. In bad cases of 
femoral hernia, an additional elliptic spring is attached 
to the iliac portion of the instrument, (to which the 
pad is attached,) which increases its retentive power. 
But few cases, however, require this additional spring. 
The form of the pad that has been found best adapted 
to this form of hernia, has a plano-convex surface, 
tapering equally on each side, leaving the convex sur- 
face half an inch in width, which should be excavated 



HERNIA. 199 

so as to prevent its central portion from acting upon 
the ligaments. The length of the pad should be about 
two inches, and the width of the portion attached to 
the spring one inch and a half. A pad of this form 
and size when adapted to the part, will escape the 
important blood-vessels and glands as far as is prac- 
ticable. When well formed with a wooden boundary, 
and covered with soft material, it will secure the 
patient against the escape of the bowel, and afford all 
the comfort that is to be obtained from any form of 
instrument. My experience in the application of the 
instrument in this form of hernia has been considera- 
ble, and, one-third of those I have attended, within the 
limits of my practice have been cured. 

Umbilical Hernia. — This form of hernia, when 
congenital, is treated with pads and bandages properly 
adjusted, and with ligatures passing around the sac 
and integument, with sufficient force to produce 
sloughing of the parts, by which the edges are united. 
But as a general agent, some form of truss is prefer- 
able as being less painful and hazardous, in the treat- 
ment of children and youth, and also to secure the 
adult from the danger of strangulation, or a further 
distension of the umbilical opening. A well con- 
structed truss, with a suitable pad and spring properly 
adapted to the body, not only keeps its place, but with 
ordinary care, is the most certain means of accom- 
plishing a cure. In the young the cure is generally 
effected through the nutritive process, if the viscera 
be kept up for a year or two ; in the adult when the 
aperture is not large, a well adjusted pad of firm 
material, may occasionally succeed by the process of 
adhesive inflammation. 



200 



HERNIA. 



Having tested most of the instruments used in this 
form of hernia and found them defective, I have con- 
structed one of late, which proves less objectionable, 
as it is less liable to misplacement, more comfortable 
for the patient, and more effectual in its retentive 
powers than any other I have ever used. 

The form of the pad secures it from passing into 
the aperture, when attached to the spring. But 
the following cut will exhibit its form, and perhaps 
enable the surgeon to determine its advantages. 




The main spring is made to pass around the body 
and rest upon pads at the upper boundary of the hip 
bones. In front is attached a circular plate of suffi- 
cient size to pass two inches above the umbilicus ; — to 
the centre, in a perpendicular line, is a thin narrow steel 
plate, attached by a hinge, with fissures or slides for 
the adjustment of the pad, which is constructed of ivory 
or wood, with two convex surfaces — the largest con- 
vexity in the centre. This form will prevent the 
viscera from protruding ; and the outer convex margin 
or rim will prevent the central part from entering 
the umbilical opening further than is necessary to 



HERNIA. 201 

retain the viscera in their proper cavity. By this 
double convexity the pad is enabled to retain its place 
on the principle of atmospheric pressure— the plate to 
which the pad is attached is also connected with two 
small elliptic springs, which are again attached to side 
straps. These pass around the body to the back 
pads where they are fastened. By this arrangement, 
the surgeon or patient is enabled to adjust the pres- 
sure according to his pleasure and comfort. 

This form of pad, I have found better than any of 
the convex pads usually worn. By it children may 
generally be cured in one or two years, according to 
the size of the opening, — where this is very small, a 
month or two will accomplish the object. In adult 
cases my cures have not been more than one fifth, 
but in every case I have succeeded in making the 
patient comfortable and secure, against stangulation. 
The parts under the pads should be sponged night 
and morning with cold water, to sustain the strength 
of the muscles. 



18 



HEMORRHOIDS, OR PILES 



This disease has become, of late years, a common 
malady, and is said to be produced by obstructions in 
the portal circulation, and other local causes; by 
constipation producing mechanical pressure upon the 
hemorrhoidal veins ; by aloetic pills and other irritating 
nostrums ; by pregnancy obstructing the returning 
veins ; by suppression of the menses, and other habi- 
tual discharges, and by excesses in eating and drink- 
ing, conjoined with sedentary habits. 

That the former is capable of producing congestion, 
of the stomach and bowels, is unquestionably true, as 
any obstruction to the course of the blood through 
the liver, must produce congestion in all the tributa- 
ries to the vena portarum. But is it to be supposed 
that this congestion is more likely to produce disease 
of the rectum, than of other parts of the alimentary 
canal, unless a previous local impression had been 
made upon the rectum by an antecedent cause ? 

That constipation is calculated to produce piles, no 
one can possibly deny ; but constipation, is itself a 
consequence of sundry defects, arising from different 
causes. Among these 7 are debility of the muscular 



PILES, 203 

coat of the bowels, deficient secretion of the liver, and 
mechanical obstruction arising from the descent of 
the sigmoid flexure of the colon into the pelvic cavity, 
where it presses upon the rectum. The displacement 
consequently produces obstruction of the bowels, and 
prevents the return of the blood from the venous 
trunks of the rectum. By the former, the bowels 
become loaded or impacted, which gradually debili- 
tates the rectum until the portion divested of its peri- 
toneal coat, becomes distended and enlarged ; by the 
latter, the hemorrhoidal blood-vessels become dis- 
tended, and from these obstructions the afflux of blood 
is determined to the rectum. This is followed by 
acute or sub-acute inflammation beneath the mucous 
coat in the cellular tissue, and constitutes those hard 
fleshy tumours, which give rise to so much pain. 
From such facts, it may then be asked, what cause is 
better calculated to produce piles than these ? 

Hence, I am inclined to the belief that the pro- 
lapsed condition of the sigmoid flexure of the colon, is 
the primary cause of this painful malady ; as obser- 
vation and experience most clearly demonstrate that 
piles mainly depend upon local causes, acting directly 
upon the rectum, and not, as heretofore believed, upon 
hepatic derangement. Instead of piles being pro- 
duced by obstruction of the liver, this organ is more 
frequently deranged in its functions as the consequence 
of piles, and their causes. 

Those who have been in the habit of exploring the 
rectum, must have observed its uniform enlargement 
one inch above the sphincter ani, at the insertion 
of the larger proportion of the fibres of the levator 
ani. The space between the insertion of this muscle 



204 PILES. 

and the peritonea] coat, is in all cases of piles enlarged 
and loaded with fleshy and varicose tumours, or both. 

In the early stages of this disease the symptoms 
are, a sense of fulness and weight in the pelvis and 
rectum, which is attributed, by the patient, to a loaded 
condition of the lower bowels. This condition being 
neglected, the varicose tumours partially give way, 
streaking the faeces with blood, or else a free discharge 
from the rupture of one or more of the soft tumours 
which have made their appearance at the anus, giving 
rise to considerable pain, and in females many nervous 
symptoms, the nature of which is often misunderstood. 
In the forming stage of the hard fleshy tumours, the 
most uniform symptoms are a throbbing, stinging heat, 
within the verge of the anus, a tormenting itching 
sensation, and a sense of fulness of the part, the mar- 
gin of which is considerably enlarged. On applying 
the finger to the rectum, there will be found irregular 
points beneath the integument, which make their 
appearance at the verge — sometimes one, sometimes 
two or three, and at other times the entire margin is 
thickened or indurated. These tumours in many per- 
sons never make their appearance externally, but are 
alike annoying and injurious to the general health, 
especially when the tumours are formed within the 
action of the levator ani muscle, where they are often 
found. 

This form of piles produces more constitutional 
derangement of the economy than any other. I have 
observed in this part of the rectum that a small tumour 
deranged the system more than one double its size 
would do above the insertion of the muscle. They 



PILES. 205 

are generally of different sizes and shapes ; — some 
almost closing the natural passage. 

This form of piles is frequently mistaken for the 
disease of the liver and digestive organs. In females, 
such tumours are frequently the cause of hysteria, 
nervous palpitations of the heart, and many other 
anomalous symptoms. 

The enlargement of the rectum above the levator 
ani muscle, and its effect upon the internal tunic, 
which is so lengthened, that during defecation, it be- 
comes prolapsed, and has to be returned by pressure, 
is sufficient evidence to prove that the disease is the 
offspring of a mechanical cause. 

At what point is the bowel most frequently per- 
forated by fistula ? Is it not at the marginal insertion 
of the levator ani muscle ? Examine the nature of the 
varicose and fleshy tumours, and say if the former is 
not produced by the mechanical pressure of the sig- 
moid flexure of the colon ; and the latter from sub- 
acute inflammation of the cellular tissue beneath the 
mucous membranes. Then if this be the primary 
cause of the disease, what should be the remedy in 
its incipient stage ? and to what should it be directed — 
to the consequences, or its cause ? It has been my 
uniform rule to treat all cases of diseased rectum with 
reference to their cause, and to obviate constitutional 
symptoms as circumstances may indicate, and I have 
yet to meet with the case that will oblige me to regret 
the adoption of this rule. 

With this view of the subject, the several indica- 
cations necessary in the treatment, will be easily made 
out, and severally met, so far as is requisite for the 

18* 



206 PILES. 

clinical practitioner. The surgeon being provided with 
an ample stock of knowledge upon his shelves, will not 
require details here, to assist him in operating for fis- 
tulous openings, excisions, or for strangulating the 
tumours. As I believe piles to be a local disease, 
depending upon causes wholly different from the popu- 
lar theory of obstruction in the portal circulation; 
hence, the general indications will be given in accord- 
ance with this belief. But as the prevailing opinion, 
in relation to the propriety of suppressing the habitual 
discharges attendant upon this disease, (which arises 
from the assumption that piles is the consequence of 
constitutional derangement,) has not, in my opinion, 
been carried out in practice, I shall endeavor to prove 
the consistency of the principles that are necessary to 
sustain my views on the subject. Every body knows, or 
ought to know, that habitual discharges, established 
either from local or constitutional causes, and permitted 
to continue for any length of time, cannot be safely 
suppressed without subjecting the vital organs to con- 
gestion. But what effect has the popular erroneous 
theory upon the well informed surgeon, who is familiar 
with the effects of local disease upon the general con- 
stitution? Will it deter him from removing the 
irritating cause, when a musket ball in a gun-shot 
wound is keeping up the discharge and constitutional 
derangement of the system ? In such cases, the judi- 
cious surgeon prepares the constitution of his patient, 
and regulates the digestive organs before he pretends 
to operate. When this is accomplished and the wound 
begins to close, gradually suppressing the discharge, 
an alterative course of remedial agents is resorted to, 



' PILES. 207 

with the intention of increasing the functions of the 
emunctories. 

By such treatment, local congestion is prevented, 
until the debilitated parts of the system are made to 
harmonize. In like manner, we find the surgeon regu- 
lating and preparing his patient for the operation in 
case of fistula ; or, when a hemorrhoidal tumour is to 
be excised, or strangulated within the rectum. If the 
same precautionary steps be observed in the treatment 
offpiles throughout the different stages of the disease, 
there will be no necessity for cavilling as to whether 
the disease arises from local or constitutional causes. 
The general indications to be kept in view in the 
treatment are, consequently, 

I. To remove the cause of the disease. 
II. To regulate the constitutional symptoms and the 

digestive organs. 
III. To suppress the excessive discharges, and remove 
the tumours by pressure, scalpel or ligature, 
and restore the bowel to a healthy condition. 
The first indication may be met as follows: by 
inverting the body or elevating the hips, or by a 
recumbent posture on the right side, while the body 
slightly inclines forward, and the thighs are flexed to 
restore the sigmoid flexure to its proper position. 
After which a supporter should be applied with its 
left inguinal cushion about an inch thicker than its 
ordinary size. This additional fulness at its inner 
margin will prevent the sigmoid flexure from descend- 
ing again into the true pelvic cavity, and thus re- 
move one of the principal causes of piles. The bow- 
els also should be regulated by the use of sulphur, 



208 



PILES. 



and cream of tartar, which with the supporter, will 
relieve many cases in the incipient stage. But if the 
digestive organs have been deranged by local irrita- 
tion, a blue pill or two should be given, with aperients, 
and assisted by injections of cold water every morning. 

The second indication to be met, will vary in 
accordance with the symptoms. If inflammation be 
discovered around the verge of the anus, from either 
form of the tumours, leeches should be applied, and 
the parts frequently sponged with cold water. If 
local disease has established vascular action, and the 
patient be of full habit, general blood-letting is indi- 
cated. In such cases, a dose or two of calomel will 
be useful, — more especially if combined with prepared 
chalk and ipecacuanha, which will act mildly and 
efficiently. If the system has become debilitated, and 
chronic inflammation is discovered in the rectum, 
with constitutional disturbance, counter-irritants to the 
loins and inner parts of the thighs, and hip bath, will 
check the violence of the disease ; five grains of blue 
mass, and four grains of Dover's powder, taken at 
bed-time, are often indicated to restore the secretions. 
The bowels should be regulated by vegetable diet and 
injections of cold water. 

The third set of indications, (two of which pro- 
perly belong to surgery,) have been sufficiently noticed 
as preparatory to the operations by ligature or the 
knife. 

Tne treatment I have adopted to restore the ali- 
mentary canal and arrest the disease of the rectum 
(without the use of the knife or ligature,) is different 
from any heretofore recommended, and I here subjoin 



PILES. 



209 



an electuary, which I have found useful with other 
agents. 

R. Inul. Helen, rad. pulv. ^iiss. 

Sem. Anis, " 5iss. 

Capsi. Afric, " 3"- 

Mel. despum, l v *" # ^. 

Of this mixture take a teaspoonful two or three 
times a day. 

This is useful as an aperient or mild stimulant, to 
regulate the bowels and restore the mucous membrane 
to a healthy condition. This article I have found to 
be more efficient in ulceration of the rectum and 
debility of the bowels, when used in conjunction with 
washes and alteratives, than any other remedy I ever 
tried. It is similar to the article recommended by Sir 
Astley Cooper, called " Ward's paste," for the treatment 
of fistula. When the disease is produced from debility 
of the muscular coat, and distension of the intes- 
tines from constipation, the alimentary canal should 
be restored to its original size by the remedies recom- 
mended in the Essay on Constipation, and this electu- 
ary, after which the local disease should be treated 
by introducing a gum-elastic sack of a conical form, 
terminating in a neck below, about five lines in diame- 
ter, to which a catheter is to be attached. This sack 
is to be introduced above the levator ani muscle, with 
the fore finger, and then the catheter will convey it to 
the junction of the rectum and sigmoid flexure, where 
it is designed to rest. Being thus adjusted at the 
upper boundary of the distended portion of the rectum, 
by attaching the end of a large syringe to the external 
end of the catheter, the sack can be inflated so as to 



210 



PILES. 



fill the bowel. The object of this, is to prevent the 
washes that are necessary in the treatment, from pass- 
ing higher than designed, and also to leave the wash 
under the control of the syringe, that it may be 
retracted at will, by this instrument. By this simple 
arrangement, the operator is enabled to select his 
washes as indicated, without risk. If the wash be 
composed of dangerous materials it can be removed ; 
but without this sac, or some similar contrivance, such 
as a fine sponge, the wash injected, would be thrown 
into the sigmoid flexure of the colon, whence I have 
found it difficult to retract it, with even the aid of a 
stomach tube. 

In one instance where the yellow wash was used, 
so much was retained that it produced ptyalism of a 
severe form, which increased the debility of the patient, 
and gave rise to unnecessary suffering. Where the 
disease of the rectum consists of mere distension, with 
debility, the veins being varicose, washes of soap and 
water, or equal parts of milk and lime water used 
once a day, and cold alum water, will speedily relieve 
the local disease. Sixty grains of alum to half a pint 
of water will make a wash sufficiently strong, unless 
a styptic effect is desired to check profuse discharges ; 
in which event, the strength of the wash may be 
increased two-fold. Where the internal tunic appears 
excoriated, lime water, milk and honey, have been 
found to restore the mucous coat to a healthy con- 
dition. During the use of the washes, of all vari- 
eties, the bowels are to be regulated by cold water 
injections, and aperients, such as sulphur and cream 
of tartar, or the electuary. Magnesia is rarely admis- 
sible in this affection. The patient afflicted with piles 



PILES. 211 

should be furnished with a syringe, and directed to 
wash out the rectum after each operation from the 
bowels, until the cure is completed. I have not found 
it necessary to wash after the first day or two, oftener 
than once in two or three days, with the medicated 
articles. 

Again, where the rectum is loaded with varicose 
and fleshy tumours, inflamed and irritable, the active 
form of inflammation must be subdued by leeching and 
general remedies, before the sack can be introduced. 
In such cases, the solution of belladonna applied within 
the verge of the anus, relaxes the parts, and prevents 
pain from the introduction of the sack. The washes, 
which I employ for the various forms of tumours, 
and morbid lesions of the mucous coat, at different 
times, in addition to those recommended in the mild 
form of the disease, are as follows : — The black and 
yellow wash, of the strength as recommended in the 
American Dispensatory — the solution of nitrate of sil- 
ver, varied in strength from four to eight grains to 
the ounce of water — and the compound solution of the 
iodide of potassium, iodine, and extract of conium. 

R. Iod. Potassium, 9j. 

Iodin, gr. x. 

Ext. Conii, 9ss. 

Aq. Fluv., f ?iss. 
M. et solve. 

At the time of using, add three ounces of water, 
which will sufficiently reduce the strength for a common 
wash, where the rectum appears to be generally thick- 
ened ; but it should not be used on high inflammation 
of the parts. The same quantity dissolved in one 



212 PILES. 

ounce of water, is of sufficient strength, to be applied 
with a sponge to the tumour, as a suppository, or 
applied by a pencil through a small speculum of two 
blades, which instrument is of great service in the treat- 
ment of tumours found within from three to three and 
a half inches from the verge of the anus. By the wash 
and the application of this compound of iodine, I have 
reduced many hemorrhoidal tumours : but the latter is 
not admissible in acute forms of the disease. The nitrate 
of silver should be used in the inflammatory form, as 
it uniformly subdues inflammation of the mucous 
membrane, which, alternated with lime water, is my 
preparatory wash during the acute stage. In some 
cases I have found the black and yellow washes dis- 
perse the tumours where the iodine had failed, and 
vice versa. In strumous constitutions the washes of 
iodine, nitrate of silver, and lime water, should be 
relied on as efficient, since mercurial action is uni- 
formly injurious where the system becomes affected 
with it. During the use of these washes the consti- 
tutional symptoms are to be attended to, as functional 
derangement or inflammatory action may indicate. 

Another or third order of the disease of the rectum, 
is that in which the tumours protrude at the verge of 
the anus. Where these are irritable and highly 
inflamed, warm emollients, alternated with cold appli- 
cations, and leeches will give relief; and as a palliative, 
different compounds of opium and tannin will be requi- 
red in the treatment of lying-in women. But I have 
found that these tumours can be removed by a suit- 
able compress — the application of mercurial ointment 
and iodine, aided by the washes and the electuary. 
The compress I use is the old T bandage, with a 



PILES, 213 

simple addition, and made by attaching two pieces of 
elastic webbing to the strap that passes around the 
pelvis, at the superior anterior spinous process of the 
ilium. This should be of sufficient length to reach the 
centre of the perineum where they are united to a 
single strap of sufficient length to reach the transverse 
strap around the pelvis, at its posterior portion, to which 
it may be fastened. There should also be attached 
on each side, a strap half an inch in width, to pass 
around the thighs. By these straps or stays, the front 
straps are prevented from encroaching upon the 
genital organs, and the bandage is more easily kept 
in its place. At the junction of these several straps 
a gum elastic or cork pad, of a wedge shape, an 
inch and a half wide at its base, its upper boundary 
rounded to an oval form, and presenting a surface one 
half an inch wide, will be found to rest easily and 
effectually on the parts. The whole should be covered 
with oiled silk or gutta percha. This simple bandage 
will enable the surgeon to apply the necessary force, 
and his pledgets of lint, saturated or covered with 
iodine or mercurial ointment, will be found effectual. 
The length of the pad may be increased to suit the 
relaxed condition of the perineum. 

By attention to the constitutional symptoms, and a 
judicious use of the washes, ointments and compresses 
recommended, with the aid of the supporter, a very 
large majority of the afflicted may be relieved, if not 
radically cured. But as before intimated, the knife or 
ligature in certain cases must be resorted to, where 
the tumours become indurated, as the only means of 
effecting the cure. 

There is a number of astringent washes, which may 

19 



214 PILES. 

be used in the treatment of the diseases of the rectum ; 
such as the decoction of oak bark, green tea, and 
sulphate of copper, all of which are frequently indi- 
cated. In the use of the injections, where violent 
pain is produced, the strength should be diminished, 
and for immediate relief starch and laudanum may be 
thrown into the bowel. 

During the treatment of the diseases of the rectum 
with the washes and remedies directed, a due regard 
must be paid to the general condition of the system, 
to prevent local determinations to new parts, as the 
discharge and morbid action is removed from the rec- 
tum. For this purpose I have found alteratives indi- 
cated ; such as an occasional blue pill, with a sufficient 
quantity of saturated tincture of the apocynum can- 
nabinum, taken daily to sustain the action of the 
bowels, to one, and not exceeding two motions a day. 
In constitutions affected with strumous habit, it is fre- 
quently more advisable to establish a drain by a seaton 
in the calf of the leg, or in the arm below the insertion 
of the deltoid muscle, than to permit the piles to con- 
tinue ; more especially if there be symptoms of dis- 
ease of the lungs. The wonderful tendency of every 
part of the mucous membrane to sympathize, one 
part with another, is so well known that it is unne- 
sary to prove the necessity of removing the disease, 
even if its removal should render it necessary to 
continue the seton for a year or two. By this course 
I have procrastinated the fatal termination of tuber- 
cular disease of the lungs for years, in some, and 
in others removed the tendency to the complete 
development of organic disease of the chest. The 
importance of removing irritation from all portions 



PILES, 215 

of the alimentary canal, must be manifest to every 
practitioner who has witnessed the extensive morbid 
alteration of the mucous membranes throughout 
the system in tubercular consumption ; and is it to 
be doubted that one of the fruitful sources of the 
many deranged conditions of the digestive organs, and 
the lungs, is owing to the neglect of an early atten- 
tion to the disordered condition of the rectum, which is 
contiguous with the principal organs of the economy. 
It is an old theory that hemorrhoidal discharges are 
the efforts of nature to free herself from some disor- 
dered condition, which, if not thrown upon the rectum, 
would be directed to other organs. This doctrine is 
really inconsistent, as it conflicts with some of the 
sound and well known principles in physiology and 
medicine. This hypothesis was founded upon the 
absurd notion of a morbid tendency of the system 
to seek a new outlet to free herself from effete ma- 
terial, which is not in accordance w 7 ith the efforts 
of nature, as observed in her movements, when not 
overpowered by surrounding causes. In such cases 
she would have her natural outlets called into exalted 
action, to throw off the effete material. I would 
ask if a morbid tendency, as some writers term it, is 
not disease in embryo, from which nature is unable to 
free herself at her natural outlets, and which con- 
stitutes morbid vascular action in some cases, and 
local disease in others ? Also, if it is not an admitted 
axiom that morbid action, when established, is known 
to make its local seat upon the weakest and most irri- 
table part of the organism ? Hence, diseases of the 
rectum should not be regarded as a new outlet, estab- 
lished by nature, but by disease produced from causes 



216 PILES. 

without and within the system. It would be equally 
consistent that hemorrhage of the lungs should be 
permitted to continue, as that of piles. Each dis- 
ease originates from similar changes, though from 
different causes. For instance, piles is the conse- 
quence of impacted rectum and mechanical obstruction 
from the weight of the sigmoid flexure, by which the 
blood is prevented from returning from that organ. 
In hemorrhage of the lungs the blood-vessels give 
way in some cases, from mechanical obstruction, 
produced by tubercles, and in others from congestion ; 
neither of which should be permitted to continue 
with a belief that nature is about to free herself from 
effete material by any new or unnatural outlets. 



GOUT 



This disease, depending upon a peculiar diathesis, 
is supposed, in some cases, to be inherited, and in 
others, generated by other incidental causes and con- 
sequences. When it appears in the regular form, it 
manifests itself by local inflammation in and upon the 
fibrous tissues, with fever. The symptoms and pro- 
gress are very irregular, and hence, it has been 
divided into acute, chronic, and retrocedent, by sys- 
tematic writers. 

In the regular or acute form, the attacks are irregu- 
lar, being once or twice in the year with some, or as 
the system becomes impaired, more frequently in 
others. After the paroxysms are over, notwithstanding 
the system is apparently renovated, it leaves it more 
susceptible, and much more easily affected from 
slighter causes. 

The premonitory symptoms are, a deranged condi- 
tion of the digestive organs, with an empty, uneasy 
feeling in the stomach, a sense of weight, and disten- 
sion of the abdomen, also with frequent acid eructa- 
tions, costiveness, lassitude, drowsiness, disturbed 
sleep, depressed spirits, giddiness, white tongue, irri- 

19* 



218 GOUT. 

table condition of the bladder, and a deep red or muddy 
appearance of the urine. The appetite is also irregular, 
being voracious at times, inefficient at others, with 
nausea and occasional vomiting. In some cases, 
numbness is experienced in the lower extremities, with 
cold feet and legs; whilst in others there are dis- 
charges from the bowels, bladder, and bronchial mem- 
branes, denoting irritation of those surfaces; and the 
general symptoms are of a gastric, or dyspeptic order, 
previous to the attack. 

The paroxysms, in the initial stage, generally com- 
mence in the latter part of the night, frequently 
arousing the patient by pain in the joints of the great 
toe, heel, or the instep, which is followed by a chill, 
or by chilly sensations that terminate in febrile re- 
action — increasing the pain and suffering. In three or 
four hours there is generally a slight remission of 
pain ; when perspiration sometimes ensues, which 
appears to be controlled by the laws that govern in- 
termittent fevers in the cold, hot and sweating stages. 

The painful and hot stages of gout, vary from four 
to forty-eight hours without remission from the com- 
mencement of the chill to the sweating stage. During 
the remission, the patient sleeps more or less quietly, but 
every succeeding evening there is a return of both 
pain and fever, which abate in the after part of the 
night. On examination, the affected parts are found 
swollen and red, and the veins enlarged. In a few 
days after the attack, the part assumes an cedematous 
character, the inflamed part being remarkably tender, 
so that the weight of the bed clothes cannot be borne 
without increasing the already torturing pain. The 
duration of an attack of gout varies from ten to thirty 



GOUT. 219 

days ; the first is generally short, but the subsequent 
attacks increase; after recovery from a regular fit 
of the acute form, the system is left in a better 
condition, and is somewhat renovated; but if the 
attack has been of the chronic order, such favorable 
restorations are not to be uniformly expected, as 
the liver suffers more or less from functional derange- 
ment, and sometimes from structural lesions. The 
stomach also, from the continuance of the disease, 
becomes permanently debilitated; and the tendons 
about the joints contracted and thickened, giving 
them an irregular and knotty appearance. 

The chronic form of gout being the consequence of 
a deficiency in the energies of the digestive organs, or 
of repeated attacks of the acute form of the disease, 
with all other grades, depending upon the acute and 
sub-acute forms, I shall confine my remarks to these 
two grades, as the other varieties are the conse- 
quences of certain morbid conditions of the stomach, 
liver, kidneys, skin and general system. 

In chronic gout the pain is most severe in the fore 
part of the night. The joint, or part affected, is 
swollen but not red, and sometimes the tumefied 
parts are of a purple color. This grade is liable to 
pass from one part of the system to another. The 
general, as well as the local fever, in this form of the 
disease, is mild, while the biliary and digestive organs 
are seriously deranged, and the tissues about the joints 
become thickened and contracted. In some cases 
there is an earthy matter deposited in the sheaths of 
the tendons under the cuticle and in the cellular mem- 
brane surrounding the joint. Where it leaves its 
external seat and attacks any of the internal organs, 



220 GOUT. 

it is termed retrocedent ; and where it is wandering 
through the system, with an imperfect local seat about 
the joints, it is called atonic gout. This form has 
been known to make its appearance on the internal 
organs without any external appearance. Hence its 
resemblance to rheumatism, and the analogy between 
the two diseases in their progress and treatment, is 
very striking; and it is more than probable that the 
difference is to be found in their predisposing and ex- 
citing causes, with the peculiar temperament and con- 
stitutional predisposition, or habits of the patients ; or 
in some cases, perhaps, where both parents are 
afflicted with the disease, their offspring may inherit 
the peculiar temperament so that the common exciting 
causes awaken the disease, though the usual predis- 
posing causes be rigidly avoided. 

The predisposing causes of gout, which are calcu- 
lated to establish a gouty diathesis in the constitution, 
where the patients are clear of the disease; are, an 
habitual use of high seasoned, nourishing animal food, 
and the regular use of vinous or fermented liquors; — 
as we find a rich diet and indolent habits will bring on 
the diathesis, and at the same time we find that vinous 
and fermented Jiquors are an excellent auxiliary. 

Of the proximate cause of the disease, there is how- 
ever, a diversity of opinions advanced by the numerous 
pathological and practical writers, and as no two con- 
cur in all the particulars, I will give my views without 
intending to refute or sustain any of the theories, and 
leave the reader to determine the correctness of the 
principles by contrasting one with the other. 

From the symptoms observed in my clinical pur- 
suits, with the appearance after death, and with the 



GOUT. 221 

history and experiments given by others, it is clear to 
me that the proximate cause of the disease is owing 
to uric acid and the retained insensible and sensible 
transpirations, that should have been thrown off. 
As we find that the functions of the skin, kidneys, 
stomach and bowels are the first deranged, so we find, 
that the favorable termination of the disease is pro- 
moted, in proportion as these functions are augmented 
or improved, whether it be acute or chronic gout. 

But it must be borne in mind that the retention of 
effete matter in the system is the consequence of other 
defects hereafter to be explained. 

It is however universally acknowledged that high 
seasoned dishes, with vinous and fermented liquors, 
are capable of establishing the gouty diathesis in 
constitutions where there is no inherited predispo- 
sition to the disease ; and also, that the chronic grade 
is owing to the peculiar condition of the system, or to 
the long continuance of morbid action established by 
the causes which give rise to the disease. Further- 
more, it is known that the chemical products which 
are found in gouty subjects, though various, are the 
results of morbid action established in the system. 
First upon the solids on which those morbific products 
are generated, and the system being incapcitated to 
throw them off by the natural outlets, they constitute 
the proximate cause of gout. No one can possibly 
believe that a child is born with a specific gouty mat- 
ter in the system; but at the same time it is equally 
evident that the offspring of gouty parents inherits a 
latent tendency from organization, ready to be called 
into action by slight causes calculated to establish the 
gouty diathesis. In all ages it has been the received 



222 gout. 

opinion that the gouty virus was generated, or pro- 
duced by the disordered and debilitated condition of 
the digestive organs, which condition is the conse- 
quence of the causes referred to in this essay. 

The succession of events that are necessary to 
establish a fit of gout, in the acute form, seems to me 
from the symptoms, progress and termination, to be 
produced and to take place in the following order : 
I. The habitual use of high seasoned animal food, 
vinous and fermented liquors, in those who are 
inactive, especially, establishes an exalted ac- 
tion of the digestive organs, from the quantity 
of blood invited to them by the materials taken 
into the stomach. 
II. The constant excited condition of the internal 
organs deranges the functions of the skin and 
kidneys. 
III. The failure of the functions of the skin and kid- 
neys leaves the system charged with effete 
material, that should have been thrown off by 
the skin and kidneys, which further deranges 
the secretions of the system, and constitutes the 
proximate cause of the disease. 
The dyspeptic symptoms, taken in connection with 
those of gout, with the blennorrhceal discharge from 
the bladder, and the yeasty ichorous green dis- 
charges from the bowels, alternating with constipa- 
tion, most clearly prove the succession of events. The 
failure of the stomach, liver, skin, and kidneys, with 
the uric acid and the effete materials, which should 
have been thrown off, show that the fluids are conta- 
minated, through the impaired condition of the solids, 
which react upon each other. In the chronic form of 



gout. 223 

the disease, the succession of events is the same, 
except the difference of the strength in the constitu- 
tion, the same causes invite a greater afflux of blood 
to the stomach than is compatible with the strength 
of the organ and its functions, which establishes a 
similar chain of morbid alterations in the system, but 
of a chronic character. But in constitutions possessed 
of great vital energy, a fit or two of the gout, not 
unfrequently so deranges the digestive organs, that 
the subsequent attacks assume the nervous or chronic 
character. In support of this position let us examine 
the opinions of others touching on the same point. 
" It is generally believed," says Professer Wood, " that 
the most efficient causes in generating the gouty 
diathesis, and consequently in promoting it when 
inherited, are the use of animal food in undue pro- 
portions, especially of high seasoned meats and soups, 
indulgence in alcoholic drinks, and sedentary habits." 

Dr. Eberle says, " The principal exciting causes of 
gout are intemperance in eating and in the use of 
spirituous liquors; suppression of habitual evacua- 
tions; violent or depressing mental affection; cold 
and humidity, redundancy of, and bile in the primse 
vise; fatigue both of body and mind." 

From the general concurrence on this important 
point, it is manifest that those causes are well calcu- 
lated to establish gout, by inviting a greater afflux of 
blood to the internal organs than is consistent with their 
functions. And where the internal tegumentary system 
has an excess of circulating fluids, there is a deficiency 
on the external surface, which impairs the functions of 
one by excess, and of the other by deficiency, and by 
a failure of the functions of the skin, with morbid 



224 gout. 

secretion in the primae vise. The kidneys are also 
deranged, as those organs are obliged to perform a 
double function in throwing off the effete material, 
that should have been thrown off by the skin. 

At the same time it is known that where there are 
dyspeptic symptoms produced by the morbid condition 
of the secretions of the stomach and bowels, the uric 
acid is found to be more abundant even in diseases 
where there is no gouty diathesis. But it must be 
understood that the kidneys, in those cases, are equal 
to the demands of nature in eliminating the effete 
material, so as to keep the fountain pure. But in 
gout, the kidneys are debilitated by their vicarious 
action, from the failure of the skin ; hence uric acid, 
and the obstructed secretions of the skin, are re- 
tained in the system, which establish gout. Some 
pathologists search for the origin of gout in the 
deranged condition of the organ, whilst others, such 
as Broussais and his disciples, consider it a simple 
inflammation of the stomach and bowels which they 
denominate gastro-enteritis, from their being supposed 
to be the chief seat of the disease. But the fact seems 
to me clear, that this disease, from the symptoms, 
cause and effect, depends upon the concatenation of 
deranged functions having their origin in the altered 
condition of the solids and the contamination of the 
fluids, which is the true pathological condition of the 
system in gout. When a critical survey is made of 
the origin, causes, symptoms, altered functions, organic 
lesions, and the therapeutical agents that are most effi- 
cient in the treatment of the several varieties of this 
disease, can it be doubted that the proximate cause of 
gout is the uric acid, and the effete material, which 



gout. 225 

should have been eliminated by the skin, this virus 
producing all the different varieties of gout treated of, 
bv the various writers. It is found that the remedial 
agents which are best calculated to correct acidity, 
determine the fluids to the skin, increase the functions 
of the kidneys, correct the secretion of the liver, and 
quiet the nervous irritation — are the anchor of hope 
in the treatment of this painful malady. 

The constant attendance of the gastric derange- 
ment, and the known tendency of these organs when 
deranged, to produce an increased quantity of acid 
within themselves, are well established ; which altered 
condition of the secretions of the stomach and bowels, 
produces various changes in the organic elements of 
the fluids, eliminated by the skin and kidneys. Hence, 
we find increased or diminished quantities of earthy 
salts, in the urine, changing the appearance from a 
white sediment, to a deep brick red, in proportion to 
the combination of the lithiate of ammonia, or lithiate 
of soda and ammonia. These changes are frequently 
met with in different diseases besides gout, such as 
chronic hepatitis, dyspepsia, rheumatism, and many 
other diseases which proceed from similar derange- 
ment of the chylopoietic organs. In these diseases 
the system is adequate through the skin and kidneys, 
to free herself from effete material. But in gout, 
from long continuance of the morbid action kept up 
by acidity of the stomach, earthy deposits are generated, 
which are found in the urine, and which the emunc- 
tories are incapable of eliminating. The experiments of 
Dr. Phillips, show that animal food has a tendency to 
lessen the lithic acid and increase the phosphatic, and 

20 



226 gout. 

that every thing which increases the action of the skin, 
has a tendency to increase the lithic, and diminish the 
phosphatic deposits. Sedentary habits and the pro- 
duction of acid in the stomach and bowels, render 
the skin inactive, which leaves the effete material 
that should have been thrown off by insensible and 
sensible perspiration, which, when retained in the 
system, is calculated to disturb the entire economy, 
and to establish diseases of different kinds. In differ- 
ent constitutions affected with gout there is a variation 
between the lithic and phosphatic diathesis. In the 
latter, besides the earthy salts referred to, is found the 
triple phosphate of magnesia and ammonia, with 
phosphate of lime, &c. 

The symptoms produced by the lithic and phos- 
phatic diatheses, are in many respects similar to those 
of gout preceding a paroxysm. The characteristics 
are pain, or uneasiness in the region of the kidneys, 
with irritation in the neck of the bladder and urethra, 
a frequent desire to void urine, with the usual dys- 
peptic symptoms, particularly acidity of the stomach, 
which makes the most prominent symptom of the 
lithic diathesis. In the phosphatic diathesis, the 
general symptoms are extreme irritability of the sys- 
tem, derangement of the digestive organs, manifested 
by flatulency, nausea, and constipation, alternating 
with exhausting diarrhoea, of variable colored stools, 
which are sometimes green, and at other times ashy 
and fermented. 

The symptoms of these two diatheses, with dys- 
pepsia, when contrasted with the symptoms of gout, 
are similar ; and it will be found that the stomach in 



gout. 227 

each is the first deranged, which is evidence that the 
altered condition of the fluids, is a consequence of 
this derangement. 

In each affection we also find the skin altered in its 
functions or color. In gout, the functions of the skin 
are deranged; in dyspepsia, its sensibility. In the 
other two affections, the functions of the skin alternate 
between an exalted and diminished action. In the 
lithic and phosphatic diatheses, the kidneys are fre- 
quently, (through the quantity of earthy salts thrown 
off by the organ,) deranged in structure, and the blad- 
der, in some cases presents a similar condition, whilst 
in others, it contains calculous formations. These 
facts show that the natural outlet for this effete 
material is by the kidneys : when these fail, as in 
gout, nature throws it to the surface, and upon the 
white fibrous tissues, where it can do the least harm. 
Were it not for this inherent power of nature to resist 
and transfer those obnoxious materials to the white 
tissues, the system would be overwhelmed with irrita- 
tion and inflammation. But the organism is so 
constructed that many of the fatal poisons have 
but little effect upon the white tissues and white 
fluids, which, if brought in contact with the more 
vascular parts, would produce morbid action or death. 
Hence in retrocedent gout, as it passes from the 
extremities to any one of the internal organs, the 
danger is increased, as the tissues are more vascular ; 
and whenever the functions of the skin, kidneys, and 
digestive organs are restored, the system frees itself 
from the effete material by these emunctories, leaving 
the patient with a renovated system, until it is again 



228 gout. 

overcome, by the same causes. Therefore I infer 
that gout may be considered as dependent upon the 
following causes. 

I. By inheritance — where both parents are affected 
with this disease, the offspring has an inherent 
predisposition in his organization, which makes 
him more susceptible to the causes calculated 
to establish gouty diathesis. 
II. The gouty diathesis is produced by highly sea- 
soned dishes of animal food, with the occa- 
sional use of vinous and fermented liquors, and 
a deficiency in the proper exercise, to keep the 
imports and exports of the system equal. 

III. The derangements of the solids are produced 

by ingestion in the stomach, and the altered 
condition of the fluids is the consequence. 

IV. The derangement of the digestive organs, dis- 

turbs the functions of the skin and kidneys, 
which leaves the system charged with effete 
materials, that should have been thrown off 
by the healthy action of these emunctories. 
V. In acute gout the lithic diathesis generally pre- 
dominates, which is owing to the inflamma- 
tory action of the system. 
VI. In chronic gout, the phosphatic diathesis pre- 
dominates, w T hich is owing to the weakened 
energies of the system. This is manifested by 
the ammoniacal odor of the breath and per- 
spiration. 
VII. The lithic and phosphatic diatheses are the 
consequence of the deranged functions of the 
chylopoietic organs, skin and kidneys. 



gout. 229 

VIII. Retrocedent gout is that form of the disease 
which leaves the extremities, and seizes upon 
the most irritable internal organ. 
From these premises which are believed to be cor- 
rect, it is manifest that the gouty diathesis is pro- 
duced by the causes above mentioned. Hence the 
disease is curable, until the digestive organs have be- 
come impaired, by organic disease. 

TREATMENT. 

The treatment of gout is necessarily divided into 
that which is required during the paroxysm of the 
acute and sub-acute forms; and that which is requisite 
during the intervals of the paroxysms; where the dis- 
ease commences under the acute form, the general 
treatment must be somewhat antiphlogistic, in ac- 
cordance with the inflammatory action and general 
plethora of the system. But it is seldom that general 
blood-letting is admissible, as there are many gouty 
constitutions which are easily prostrated by the loss 
of a small amount of blood taken from the arm or 
foot, and as metastasis to some one of the internal 
organs is liable to follow. In cases where the inflam- 
mation is violent about the joints, and general re- 
medies fail, leeching and cupping are indicated. 

The most prudent antiphlogistic course, is that of 
cathartics of a mild character, with alteratives, dia- 
phoretics, and diuretics. By this course the remedies 
correct the morbid condition of the system, and 
gradually remove the local disease. In the use of 
purgatives of any kind, it should be understood that 
as the disease is produced by the derangement of 
the stomach, and the altered condition of the secre- 

20* 



230 GOUT. 

tory organs, no irritating purge should be adminis- 
tered, or permitted to act so freely as to produce 
exhaustion ; as either would be liable to invite the 
gout to the stomach or bowels. When the liver is 
torpid, a moderate dose of calomel should be given, 
and followed in eight hours by magnesia and epsom 
salts, or any saline cathartic, to free the primae vise 
from acrid secretions. After which the bowels should 
not be moved more than once or twice in twenty-four 
hours. For this purpose the liquid form, or common 
magnesia, with twenty or thirty minims of the wine of 
colchicum may be given every six or eight hours, 
according to the urgency of the symptoms. In some 
constitutions this quantity of colchicum will produce 
excessive nausea, or act as an irritant upon the bowels ; 
in either case the dose should be diminished, or less 
frequently given ; and if the irritation of the bowels 
should continue, when the inflammatory* symptoms 
have been subdued, a full dose of Dover's powder 
should be given at bed-time. In the use of colchicum, 
no barrier is presented to the employment of any 
other purgative ; this is of great advantage, as the 
liver is so frequently deranged, requiring an occa- 
sional use of a moderate dose of calomel, or blue 
mass, to regulate the secretions, either of which when 
resorted to, should be purged off' by a dose of magnesia 
and epsom salts. Colchicum and purgatives are indi- 
cated, with Dover's powder, or black drop, (to abate 
the irritation,) where the active form of inflammation 
has been subdued; these will generally restore the 
patient to ordinary health. But in some constitutions 
the colchicum seems to fail in determining the fluids 
to the surface, and in promoting the secretory func- 



GOUT. 231 

tions of the kidneys, and fails to give the prompt 
relief that is usually expected. In such cases it will 
generally be found that the patient has acidity of the 
stomach and bowels, with high colored urine; when 
the bicarbonate of potassa, given in conjunction, two 
or three times a day, will give relief, where the col- 
chicum alone has failed. The dose of this alkali is 
half a drachm. The decoction of dandelion I have 
found a valuable adjunct to the colchicum and bicar- 
bonate of potassa. Where there is much irritation of 
the kidneys and urinary passages, and much listless- 
ness from the morbid condition of the skin, the spirits 
of nitric ether may be advantageously added to the 
decoction of dandelion. 

When acute gout attacks one of the internal organs 
in the commencement of the disease, or by metastasis 
from the extremities, it must be treated in accordance 
with the importance of the organ, and the violence 
of inflammatory action. Bleeding from the arm 
sometimes becomes necessary to save life, as the 
danger is owing to the local seat of the disease. 
Where the pulse is strong, a resort to the most effi- 
cient agents is necessary to prevent inflammation. 
Leeching or cupping over the inflamed organ, is 
frequently required, with the use of sinapisms and 
blisters, the salutary effect of which is much increased 
by a warm emolient cataplasm applied as soon as the 
plaster is removed : the treatment subsequent to the 
acute stage of attack on the internal organs, is the 
same as directed in the general treatment. 

The treatment of the local inflammation of the 
joints, rarely requires more than quietude of the part 
affected ; but where the inflammation is violent, and 



232 gout. 

threatens internal injury to the joint, a few leeches 
should be applied, after which warm water should be 
poured upon the joint until the pain is subdued. When 
the pain is thus overcome, the joint should be covered 
with a wilted cabbage leaf or a warm cataplasm of slip- 
pery-elm bark. Over the cataplasm or leaf, a flannel 
roller should be applied, of sufficient tightness to give 
support to the feeble vessels without producing pain. 
By the use of the warm w 7 ater, roller and cataplasms, 
alternated and frequently changed, I have been enabled 
to control the inflammation and mitigate the suffering 
without leeches, affording more comfort than can be 
procured from all the lotions in use. 

Chronic Gout. — The treatment in this form of the 
disease, diners but little from the constitutional course 
in the acute form. Purgatives should be cautiously 
administered to remove constipation, and not per- 
mitted to act too frequently. The colchicum should 
be similarly used, or rather less frequently ; and where 
it irritates the bow r els, a few drops of laudanum should 
be given with each dose. Where there is much rest- 
lessness and pain, and general remedies fail to relieve, 
Dover's powder or hyoscyamus should be given in 
sufficient doses to quiet the system. To regulate the 
bowels, where an alterative is not indicated, the most 
efficient purgative is two drachms of rhubarb in a gill 
of boiling water. To this, after being covered thirty 
minutes, strained or filtered, add one drachm of soda 
and fifteen drops of the essence of mint ; one-third of 
this should be given every three or four hours until the 
bowels are moved. The bowels should be moved at 
least once every day, and not exceeding twice, as the 
system may be reduced to a point from which it will 



GOUT, 



233 



not easily recover. In this form of the disease the 
liver and kidneys are so frequently deranged, with a 
general debility of the stomach and bowels, I have 
found it advisable in some cases to discontinue the 
use of the colchicum after the first violent symptoms 
were subdued, and to substitute a decoction of dande- 
lion, with the bicarbonate of potassa or soda ; and 
where considerable debility exists, the cold infusion of 
the prunus virginiana is an excellent tonic for the 
stomach. The decoction of dandelion should be 
made by boiling three ounces of the root in a quart of 
water down to a pint, which quantity is sufficient for 
each day, with one drachm of the bicarbonate of 
potassa, or one drachm and a half of soda. The soda 
may be omitted as soon as the acidity of the stomach 
is removed and the secretions of the kidneys estab- 
lished. The blue pill, combined with one grain of the 
extract of conium, to three of the mass, has given 
more satisfaction as an alterative, than the mass 
alone. Where the bowels are inclined to constipa- 
tion, and the liver becomes torpid, a pill formed of 
equal parts of aloes and blue mass, will prove a good 
aperient and alterative. The pill which I have been 
in the habit of using is composed of blue mass and 
aloes, of each one drachm divided into twenty-four 
pills, one of which should be given every second or 
third night until the secretion of the liver is established. 
In chronic gout, opium, in some one of its forms, is 
more frequently required than in the acute form, and 
more especially where the atonic form gives rise to 
great nervous irritation. In such constitutions, a half 
grain of ipecacuanha, ten grains of soda, and one 
sixteenth of a grain of the sulphate of morphia, 



234 gout. 

given in one ounce of water every four hours, will 
quiet the nervous irritation, and abate the low febrile 
action. The morphia should be increased where the 
stomach is very irritable, and the ipicacuanha dimin- 
ished. The cimicifuga racemosa, in this form of 
the disease, is more soothing to the nervous system 
than the opium, though not so prompt in its effect ; 
yet it is as certain, where the system is brought 
under its influence, as its effect is durable. Put 
two drachms of the root coarsely powdered, into a 
half pint of water, which, after boiling ten minutes, 
should be left till cool and filtered. The dose of the de- 
coction, is two drachms every three hours, taken in the 
dandelion decoction, if the kidneys are deranged ; or 
in the cold infusion of the prunus virginiana, if the 
stomach is debilitated. This article, when given in 
combination with those articles, as indicated, will be 
found, in addition to its soothing action upon the ner- 
vous system, both tonic and alterative. When the 
gout is thrown upon the lungs, and produces the symp- 
toms of asthma, the decoction, or the powdered root, 
will give more certain relief than any other remedial 
agent ; but when there is febrile action, three grains 
of ipecacuanha and one drachm of soda should be 
mixed in three ounces of water, half an ounce should 
be given every three or four hours, as the symptoms 
demand and the stomach will bear, without suffering 
too great nausea, — or if there is a harassing cough, 
three or four drops of laudanum to each dose of 
ipecacuanha should be given to remove the irrita- 
tion. 

In this chronic grade of the disease, a separate 
species of nervous gout has been noticed by many of 



gout. 235 

the writers, perhaps from its wandering tendency and 
diversified violence. But this division is better calcu- 
lated to divert the mind from the true seat and nature 
of the disease than to assist in discovering its charac- 
ter, or the remedial agents indicated ; — as it must be 
manifest to every observant physician, that the ner- 
vous gout is owing to the same cause as the acute or 
sub-acute forms, and the only difference is due to the 
morbid condition of the nerves at their extreme termi- 
nations on the two tegumentary systems. The nerves 
which terminate upon the internal tunic of the bowels 
are brought into this condition, by their morbid 
secretions, which either establish a chronic grade 
of inflammation, or a morbid irritability, producing 
the same effect, and by the uric acid being thrown 
to the surface, their extreme terminations are simi- 
larly deranged. Hence this nervous condition, in 
chronic gout, is influenced by changes in the atmos- 
phere, like rheumatism, in proportion to the derange- 
ment of the functions of the digestive organs ; and 
as the secretions and strength of the digestive or- 
gans improve, so is the abatement of the neuralgic 
condition ; which makes it manifest that the loss of 
tone of the organism, with the deranged condition of 
the functions, and the irregular form of the morbid 
action, gives rise to those irregular seats of the dis- 
ease in different parts of the body, requiring such a 
variety of remedial agents. For instance, in some 
cases the inflammatory symptoms require leeching, 
cups, colchicum, saline cathartics, alteratives, sina- 
pisms, blisters, &c. ; whilst in the intermittent form, 
where the disease assumes the character of inter- 



236 gout. 

mittent fever, with regular paroxysms, quinine given 
in large doses gives relief; and where the system 
is anaemic, chalybeates are required; and in the neu- 
ralgic form, the saturated tincture of the apocynum 
cannabinum, given in sufficient doses three times a day, 
to regulate the bowels, with a full dose of Dover's 
powder at bed-time, where the pain is severe, will be 
found an efficient remedy. In cases where the disease 
assumes the character of chronic rheumatism, the 
same tincture as above mentioned, mixed with equal 
parts of the ammoniated tincture of guaiacum, and 
given three times a day, will remove the disease. 
A half a drachm of each is the quantity I have been 
in the habit of giving; and at the same time when 
there is extreme debility, the subcarbonate of iron 
should be given in full doses, every night at bed- 
time. Where the chronic gout attacks, or is trans- 
lated to the internal organs, the irritation or func- 
tional derangement is not materially different from that 
produced by other causes. Hence, in gastric derange- 
ment, it should be treated as if it was produced from 
dyspepsia; and the same may be said of the lungs, 
liver and bowels ; the secretion must be corrected, 
the irritation controlled by the use of anodynes ; and 
the local congestion removed by rubefacient embroca- 
tions, frictions, &c. In chronic gout, throughout the 
entire treatment, it must be borne in mind that the 
failure of the functions is owing to the debilitated con- 
dition of the organs, and consequently it is absolutely 
necessary to husband the strength of the patient during 
the treatment ; and, as the disease passes off, to invigo- 
rate the digestive organs as rapidly as possible, by 



, gout. 237 

exercise, mild tonics, and alterative medicines, as will 
be shown under the head of " treatment for the change 
of the diathesis." 

The local treatment of the inflamed joints in some 
cases requires the use of some remedies in addition to 
those recommended in the acute forms of the disease ; 
but local applications, if not cautiously used, are more 
likely to do harm than good. Cases which require 
warm water, cataplasms, and flannel rollers, as directed 
in the acute form of the disease, may sometimes re- 
quire leeching, though this is rare. In those cases 
where warm water fails to give relief, steaming the 
joints with the vapor of vinegar, soothes the part, and 
enables the constitutional remedies to control the mor- 
bid action. Where the joints are enlarged, and the parts 
left sore and cedematous, the camphorated liniment, 
applied twice a day, before applying the slippery elm 
cataplasms and roller, frequently facilitates the action 
of the absorbents, in the removal of the soreness and 
swelling. The local remedies to remove gouty con- 
cretions, where the parts become ulcerated, are very 
much the same as those recommended for inflamed 
gout. The part should be regularly dressed with 
warm slippery elm poultices ; and nature, assisted by 
the use of bandages, or such chemical applications as 
the condition of the parts may indicate, will speedily re- 
move the chalky concretions. For the enlarged, or 
thickened indolent tumours, that sometimes form on 
the tendons, a vinegar vapor bath, a Burgundy pitch 
plaster, worn upon the part, and the bandage, will give 
relief. Where the tendons become contracted, the same 
applications and same remedies, aided by frequently 

21 



238 gout. 

pouring warm water upon the parts affected, and keep- 
ing them warm with silk, fur or buckskin, to prevent the 
atmosphere from acting upon them, will restore them 
to their natural action, unless the general health is re- 
duced below the standard of recovery. In which case, 
no set of remedies can do more than palliate and pro- 
crastinate the morbid tendency. In the treatment of 
acute or sub-acute paroxysms of gout, I have given 
no directions for the diet that is necessary to be used, 
as such directions can only be given by the physicians 
in attendance. 

Having thus closed my remarks in relation to the 
treatment of the paroxysms of gout and their various 
stages, I shall proceed to the consideration of the 
treatment necessary to free the system from the gouty 
diathesis. 

Where this diathesis is of long standing, I readily 
concur in the opinion, that it cannot be removed; but 
as the causes of the disease are under the control of 
the patient, it follows, that where organic disease has 
not commenced, the cure is also under our control. I 
therefore protest against the hypothesis advanced by 
writers, " that we cannot remove the diathesis." 

The time to effect a cure of gout, is during the 
interval of the paroxysms. The treatment during the 
paroxysms is designed only to remove the morbid ac- 
tion in the system produced by antecedent and proxi- 
mate causes. The treatment for the cure of the 
disease is to be found in the course that will remove 
the cause and restore the impaired functions of the 
organism, by prophylactics adapted to the morbid 
condition of the system. 

The remedies that have hitherto been recommended 



gout. 239 

to moderate, or to prevent a recurrence of gout are 
numerous, but it must be manifest that all remedial 
agents are alike abortive as long as the cause that 
gives rise to the gouty diathesis is constantly in action. 
But would this be the case, if the causes, (by suitable 
remedies, diet and exercise) were removed, and the 
healthy action of the stomach, liver, kidneys and skin 
restored ? I believe the medical world would answer 
this question in the negative ; for it is known that the 
gouty diathesis, even where it had been of long stand- 
ing, has been removed by daily labour being substi- 
tuted for luxurious indulgences; which conclusively 
shows that there is not so much danger, as some 
authors would imagine, in changing old and long 
established customs, which, if continued, must neces- 
sarily shorten the life of the patient, or render him 
incapable of enjoying the span allotted to his exist- 
ence. From my own experience, and the experience 
of ages, it is proved that many have been relieved, 
even though their paroxysms have been numerous, by 
a well directed course of remedial agents, diet and 
exercise ; but not without the patient concurs in the 
prescriptions and boldly and resolutely adheres to the 
directions. In the early stages, self-government and 
resolution alone, in exercise and diet, have in many 
cases removed the gouty diathesis ; but after the 
digestive organs and the nervous extremes become 
morbidly deranged, upon the internal and external 
tegumentary systems, it requires not only courage and 
confidence, but the assistance of art to aid in restoring 
the organism to a healthy balance. 

The principal causes of this disease, as before stated, 
are, a too free use of vinous and fermented liquors, and 



240 GOUT. 

highly seasoned dishes of animal food, without exer- 
cise necessary to carry off its effects, added to a here- 
ditary predisposition. But I do not believe the use of 
spirits is capable of producing the gouty diathesis with- 
out the collateral accompaniment of rich animal food 
and sedentary habits ; and the latter will produce the 
disease without the addition of the liquors. In some 
constitutions, however, the two combined will neces- 
sarily develope the disease much earlier than diet alone. 
Hence the primary cause is generally under the control 
of the individual, not only to effect a cure of the disease 
in its incipient stage, but to assist the remedies in re- 
moving the diathesis of long standing. In the cases 
where long continued functional derangement has 
produced organic disease in some of the vital organs, 
remedies can only procrastinate the fatal tendency and 
mitigate the suffering of the patient. 

As a well regulated course of diet, exercise and 
clothing are sufficient without additional aid, to free the 
system from the gouty diathesis, it will be necessary to 
notice each before proceeding with the treatment. 

Diet, being one of the remedial agents in the treat- 
ment of gout, it should be borne in mind that the ner- 
vous extremities and capillary vessels of the mucous 
membrane of the stomach and bowels are the first 
deranged by the direct application of food and drink ; 
and I believe it may be assumed as a pathological 
axiom, that the functions of secretion are never de- 
ranged without irritation being established in the 
extreme capillary vessels and nerves. Hence the 
necessity, in the treatment of gout, for the removal of 
the diathesis, that the diet be easy of digestion and 
taken in moderate quantities. Where the food resists 



GOUT. 241 

or burdens the digestive powers, besides making a 
direct irritating impression upon the stomach, it not 
unfrequently is thrown into ferment, and evolves new 
products in this organ — such as gas, acidity, &c, which 
increase the irritating qualities of its contents. Be- 
sides these consequences, from the retention of the 
materials in the stomach and bowels, the muscular 
coat of the alimentary canal is debilitated by the over 
distension produced by the gas, which derange the 
functions of the liver, skin and kidneys, and soon 
establish the paroxysms. Where this condition has 
been once produced, very slight errors in diet, assisted 
by sedentary habits, produce a recurrence of the dis- 
ease. Consequently, no general rule or course of 
diet can be made out that would meet the diver- 
sified condition of the secretions and debilitated 
organs of the system, further than to direct the pa- 
tient to avoid all articles of diet that are difficult of 
digestion, and in proportion to the debility of the sto- 
mach and inflammatory symptoms, to diminish the 
quantity and quality of the articles used. Notwith- 
standing there is no general rule in relation to quantity 
and quality, the gouty patient should avoid roast beef, 
smoked meats, rich soups, butter, veal, fresh pork, 
ducks, geese, fish, clams, lobsters, pastry of all kinds, 
fruits, pickles, and all the vegetables in use, except toma- 
toes, common and sweet potatoes, when at maturity. 
Half grown potatoes are very indigestible; but there is 
an abundant list of articles left for the invalid ; and 
experience will soon enable him to select that which 
is most easy of digestion. In all cases the quantity is 
more to be dreaded than the quality. Bread should 

21* 



242 gout. 

be well baked and used cold, — coffee and green tea, if 
used at all, should be used sparingly. 

Exercise in the open air, on horseback or otherwise, 
should be taken every day, in proportion to the 
strength, and the quantity of food taken into the sto- 
mach. The best time for exercise is from sunrise 
until eight o'clock in the morning, and from four until 
seven in the evening. In the winter from two until 
four. The clothing should be warm with flannel worn 
next to the skin. That which is worn during the day 
should not be worn at night, as the insensible per- 
spiration is likely to be absorbed, and of course per- 
petuate the gouty diathesis. The feet should be kept 
warm and dry. 

By exercise, diet and the proper clothing, where the 
digestive organs are not impaired by the gouty dia- 
thesis, the disease may be removed without the assist- 
ance of medicine. But where the dyspeptic symp- 
toms have been fully established, with derangement 
of the functions of the liver, skin and kidneys, it will 
require the joint efforts of the patient and the skill of 
the physician to free the system from the morbid 
action. 

TREATMENT. 

The treatment of the gouty diathesis for the final 
cure of the disease, for the convenience of illustration, 
will be divided into two orders. That which will be 
proper in constitutions where the system apparently 
recovers during the intervals of the paroxysms, except 
the derangement of the stomach and the alternate 
derangement of the bowels, will first receive attention. 



gout. 243 

The next object of the practitioner will be to assist 
the enfeebled organs in the performance of their func- 
tions. 

Where the system has been so far deranged by the 
morbid action, as to disturb the functions of the sto- 
mach, liver, kidneys and skin, during the intervals of the 
paroxysms, manifested by alternate derangement of the 
stomach and bowels, it will require considerable care 
in the use of the remedies, to adapt them to each indi- 
vidual case, so as not to debilitate the general system 
with the remedies required to assist the organs in the 
performance of their functions. For this purpose, to 
restore the failure of the liver, kidneys, skin, stomach 
and bowels, the saturated tincture of the apocynum 
cannabinum, as before directed, will regulate the bowels 
without producing debility, as it is alterative and tonic 
when administered in small doses. This tincture 
harmonizes, in combination with dandelion, eupato- 
rium, prunus virginiana, and the various preparations 
of iron, with the mercurials, — such as pills composed 
of equal parts of aloes and blue mass, combined with 
ipecacuanha, which have been found in their action 
sufficient to sustain the secretions of the liver, where 
the dandelion and apocynum had failed to produce 
the desired effect. 

The pill which I have used in my practice was 
formed of aloes and blue mass, of each one drachm, 
and ipecacuanha one scruple, mixed and divided into 
thirty pills, one of which was given every third or 
fourth night, until the secretion of the liver was estab- 
lished. But where the muscular system is much 
relaxed, the extract of the podophyllum should be 
substituted for the blue mass, or five drops of the 



244 gout. 

saturated tincture of the sanguinaria canadensis, given 
night and morning, with the tincture of the apocynum 
— either of which will act effectually on the liver, and 
should be discontinued as soon as the effect is pro- 
duced. In cases where the tincture of the apocynum 
fails to restore the functions of the skin, the warm 
decoction of the eupatorium perfoliatum should be 
given in the afternoon, of each day, until the skin is 
brought to a healthy condition. One ounce of the 
plant to a pint of boiling water, will make the decoc- 
tion of sufficient strength, which should be taken in 
two or three ounce doses every three hours, until 
perspiration is induced. Where the kidneys are not 
relieved by the tincture, the extract of dandelion, 
given every night at bed-time in the usual doses, or 
the decoction made from the fresh root, (which is 
preferable,) should be substituted. Three ounces of 
the root, may be boiled in a quart of water to a pint ; 
a wine-glass full of this, given every three or four 
hours will restore the kidneys, and at the same time 
increase the functions of the liver and diminish the 
action of the heart. 

In constitutions where the general alterative course 
fails to improve the tone of the stomach, the cold 
infusion of the prunus virginiana, or the cold decoc- 
tion of the eupatorium, in small doses, is an admirable 
tonic. Where the patient is afflicted with diarrhoea, 
the tincture of the apocynum should be given in small 
doses, varying from ten to twenty drops, three or 
four times a day; and every second or third night, a 
small dose of scorched rhubarb, to check the too 
frequent discharges. The tincture alone, in small 
doses, I have found in mucous diarrhoea, equal to any 



gout. 245 

alterative ; but in some cases, it may require the aid 
of a dose or two of calomel and Dover's powder, 
where the failure of the liver is the chief difficulty. 

In chronic gout, where the muscular system and 
the digestive organs are constantly deranged, from 
the long continuance of the gouty diathesis, or other- 
wise from an originally feeble system, the entire sur- 
face should be washed with two parts water and one of 
rectified spirits, every morning, and wiped dry w 7 ith a 
soft napkin, as harsh or rough articles have an injurious 
effect upon the skin. The bowels will be regulated 
by the saturated tincture, given in small doses two or 
three times a day. The decoction of dandelion is a 
mild tonic and a valuable alterative in chronic gout. 
In this form of the disease, if the stomach is much 
deranged, tonics and alteratives combined are required. 
For this purpose, I have found the compound tincture 
of prunus virginiana, as directed in page 88, in stru- 
mous habits, to quiet the nervous irritation, and 
invigorate the stomach, when given in drachm doses 
three or four times a day. During the use of the 
tincture, the acidity of the stomach will be corrected 
by soda or bicarbonate of potassa, and the bowels 
regulated by the tincture, or the aperient alterative 
pill, directed in the first form of this diathesis. In 
some constitutions, the stomach requires a stimulant, 
tonic and diuretic combined. For this purpose, I have 
found the following compound answer the purpose : 
Take xanthroxylum fraxineum, bark of the root, half a 
pound coarsely powdered — dandelion root, one-fourth 
of a pound bruised — cistus canadensis, one-fourth of 
a pound, of the root and plant coarsely powdered — 
diluted alcohol, two pints — macerate for fourteen days, 



246 gout. 

express and filter. This tincture is tonic, diuretic, 
stimulant and alterative ; and may be given advan- 
tageously in all cases where the skin has assumed a 
yellow hue, or a dropsical aspect. If there are febrile 
symptoms it is contra-indicated. Dose as a tonic, 
one drachm three times a day, to be increased to a 
drachm and a half after it is continued a fortnight. 

The remedial agents already recommended, will, in 
a majority of cases, remove the gouty diathesis ) unless 
one of the important organs has become too far pros- 
trated to be restored by their use. For instance, if 
the liver and stomach are not restored to a healthy 
condition by the alteratives and other remedies directed, 
nitric acid should be given as an alterative and tonic. 
This acid, when given in extreme debility of the mus- 
cular coat of the stomach, and insufficient secretion 
of the liver, has been found a prompt agent in im- 
parting tone to the enfeebled organs. My mode of 
administering, is to commence with five drops, three 
times a day, mixed in a wine-glass full of flaxseed tea, 
which should be taken through a quill, to prevent the 
acid from acting on the teeth. The dose should be 
increased one drop every other day. and continued 
until its effect is produced, which will be manifest from 
a red streak in the centre of the tongue, when it 
should be discontinued, and a tea, made of two 
drachms of coarsely powdered columbo, in a pint of 
boiling water, and two drachms of soda, added subse- 
quently, should be taken. A wine-glass full of this tea 
morning, noon and night, commencing its use on the 
third morning after having discontinued the acid, will 
be found to improve the condition of the stomach and 
augment the secretions of the liver. The soda in this 



gout. 247 

infusion, should be increased in quantity where the 
stomach is inclined to acidity, as alkalies, in a ma- 
jority of cases, will not only be found a corrector, 
but a curative agent. In all cases I have found 
soda preferable to any other alkali where there was 
no lithic deposit in the urine; but in cases where 
this deposit is manifest, the preparation of potash 
is preferable. Consequently the alkaline prepara- 
tions are to be used in connection w r ith any of 
the general remedies, as the tendency of the sto- 
mach to acidity, or deposit in the urine, may indi- 
cate. These remarks are intended to apply to all 
grades of gout. 

In this third grade of derangement, from the pros- 
tration of the digestive organs, and the morbid con- 
dition of the nerves, terminating upon the internal 
tunic of the alimentary canal, and the external sur- 
face it requires, to meet the diveifeified indications, 
both a general and local treatment to improve the 
tone of the system; for so long as the wandering 
neuralgic pain pervades the economy, the patient is so 
much disturbed that the functions of the organism are 
kept unhealthy. Hence the frequent demand for the 
use of opiates and anodynes in this nervous form, 
which is the most intractable in the gouty diathesis ; 
which in many, is owing to a scrofulous diathe- 
sis existing in the system previous to the generation 
of gout. In others, the organic alteration of the 
liver, stomach, bowels and nerves, is the cause of 
the disease. Therefore, besides the remedial agents 
already mentioned for this wandering grade, I have 
found, by giving the saturated tincture of the apocy- 
num cannabinum, combined with equal parts of the 



248 gout. 

tincture of guaiac, in doses from half a drachm to a 
drachm, morning, noon and night, to move the bowels 
once or twice a day, the neuralgic suffering will 
be relieved and the general system improved. In 
some constitutions, however, the tincture of guaiac 
is too stimulating, owing to the organs of the chest 
being affected, or to the extreme irritability of the 
stomach. In either case, the same quantity of the 
tincture of cimicifuga, added to the tincture of the 
apocynum, readily controls the nervous system, and 
frees the organs of the chest. The cimicifuga is 
an efficient agent in the treatment of the diseases of 
the chest, arising from any cause, except where high 
inflammatory action is established. By alternating the 
three tinctures, the atonic or wandering gout of the di- 
gestive organs, kidneys and skin, will be removed in all 
cases where there is no organic disease. Chronic rheu- 
matism is relieved by the use of the same remedies. 
The compound ammoniated tincture of guaiac, is 
preferable in some cases to the tincture. The apocy- 
num combined with these tinctures, controls their 
stimulating tendency, as this is emetic, cathartic and 
diuretic. The quantities of the apocynum directed 
throughout the treatment of gout, are designed to 
act as aperient, alterative, and diuretic; and when 
combined with other articles, facilitates their action. 
For instance, where it is given in combination with 
dandelion, it increases the secretion of the kidneys 
and liver, when in combination with the eupatorium, 
the skin, &c. The strumous habit being so generally 
extended throughout the human family, a very consider- 
able number of patients afflicted with chronic gout or 
rheumatism, will be found much benefited by taking 



gout. 249 

the compound fluid extract of the cimicifuga as directed 
at page 91, in strumous habit; and where the symp- 
toms denote derangement of the mesenteric glands, 
the hydriodate of potassa and iodine in the fluid 
extract, as above directed, will be useful. The frost 
wort in this compound is a] powerful alterative, and 
is well adapted, in such cases, to restore the secre- 
tions and fluids to a healthy condition. 

The external remedies required in the course of the 
treatment to remove the gouty diathesis from its local 
seats, are bandages, cold and warm water, applied 
generally to the parts affected. If the joints be affected 
and enlarged, warm water should be poured upon them 
for at least one hour every evening, and flannel ban- 
dages applied around the part as directed in the use 
of the roller. Where neuralgia is wandering more 
or less throughout the system, with a relaxed condi- 
tion of the muscles,— if there is no marked organic 
lesion of the liver or organs of the chest — the patient 
should take the cold water sweat, once a week, by 
being wrapped in wet sheets twenty or thirty minutes, 
or, until free perspiration is established. For this 
purpose, two sheets should be wet and wrapped 
around the body, with two blankets over these, and 
w r arm applications to the feet and knees, until the sys- 
tem fully reacts from the shock of the cold water, 
which will occur in from ten to twenty minutes. In 
cases where the patient is fleshy, the sweating may be 
continued one hour, but if he be feeble, the wet sheets 
should be removed in fifteen minutes, and dry blankets 
wrapped around the body. To promote a free perspi- 
ration cold lemonade should be drank freely, until it 
is fully established. 

22 



250 GOUT. 

By thus sweating the patient every six days, the 
stiffness, soreness and pain, throughout the system will 
be removed. During the intervals, the patient should 
wear a suspensory jacket, or a supporter, or roller 
around the body to retain the viscera of the abdomen 
in their proper position, which will enable them to 
perform their functions. In a large majority of cases 
of nervous gout, and rheumatism, the morbid lesion, 
in such grades of the disease, is to be found in the 
nerves of the internal tunic of the alimentary canal ; 
and hence, one of the primary causes, that perpetuates 
morbid action, is owing to the muscular coat of the 
intestines having lost its tonicity, from the frequent 
distensions produced by the gas generated in them. 
In such cases the roller and the supporters, with, the 
inversion of the body or the elevation of the hips, to 
restore the viscera to their proper position, are indi- 
cated. The rest of the external remedies required for 
the joints, are the same as recommended in the 
chronic grade of the disease, during the attack of the 
paroxysm. 

Where the internal organs forbid the use of the 
cold sheet, the warm one used in the same way, will 
do much towards restoring the system ; more espe- 
cially, if the invalid will wash the surface every morn- 
ing with two parts tepid water and one of spirits, as 
the skin must be kept healthy if a cure is expected. 
It is impossible to remove the gouty diathesis where 
the functions of the skin are impaired. 

Cold water being a heroic remedy in the treatment 
of the disease, will require the best judgment of those 
who are acquainted with the organism of man, to 
direct its use — under such control it is one of the 



GOUT. 251 

most invigorating agents in the hands of the phy- 
sician. But in the hands of the pretender it is not 
only useless, but dangerous, and notwithstanding it 
should be resorted to much more frequently than it 
has been, as it is a potent and useful remedy when 
timely and skilfully employed, yet it should not be 
recommended to the exclusion of other agents. 

In conclusion, therefore, permit me to say, if the 
principles laid down in this essay are found correct, I 
hope they will be followed to the advantage of the pro- 
fession and the afflicted. If wrong, perhaps my mis- 
conceptions of the animal economy may lead to further 
investigation, and eventually to the true causes and 
consequent judicious treatment of the disease. 



THE TONGUE. 



The tongue being covered by a mucous coat which 
is continuous throughout the stomach and bowels, 
makes the appearance of this organ of more than 
ordinary importance, as an index to the numerous 
morbid changes to which the system is liable. I pro- 
pose therefore a brief notice of some of the various 
alterations in its appearance as an assistant in detect- 
ing the true character of disease. 

In the examination of this important organ, the 
condition of the fauces and mouth should be closely 
noticed, as those parts influence very much the size 
and color of the tongue, even in cases where the gene- 
ral system is not deranged. 

The tongue is so intimately connected with the 
digestive organs, and the cavities of the chest and pel- 
vis by contiguous sympathy, that it is an important 
diagnostic of disease ; but as its appearance varies in 
different diseases, in proportion to their violence and 
local seat, I shall first notice the alterations peculiar 
to febrile diseases, acute, and sub-acute inflammations; 
and, secondly, those of debility, as in chlorosis, &c. 



THE TONGUE.. 253 

First. — In fevers, from simple functional derange- 
ment, the tongue is soft and slightly covered with a 
white fur, being more or Jess lubricated with salivary 
secretions, indicating partial suspension of the natural 
secretions. If the liver be the principal organ de- 
ranged, the fur, in a few days, will assume a 'sallow 
hue, with a diminished moisture of the tongue. This 
color and appearance will then be subject to daily 
change, if high irritation or inflammation supervene, 
and in proportion to the degree of morbid action will 
the coat change from a yellow to a dry brown appear- 
ance; but if the attack be within the alimentary canal, 
the changes of the organ will vary in proportion to the 
violence of the irritation, inflammation and local seat. 
An irritable stomach in febrile disease produces a 
white fur ; if the irritability be increased, the tongue 
not nnfrequently becomes clean, dry, and of a florid 
color. When the duodenum becomes the local seat 
of irritation or inflammation, the tongue is not gene- 
rally as dry as when the stomach is similarly affected, 
and is more inclined to assume a bilious fur, though 
in other respects is similar in appearance. When the 
force of febrile action is thrown upon the jejunum, 
it varies from a natural appearance, through all the 
shades from white to a black dry coat; the tongue 
being more or less affected with nervous tremor. 
When the ileum is the local seat, it is coated most 
generally with a slightly whitish fur, which is liable to 
pass off in flakes, leaving the organ smooth, with a 
glossy red appearance; sometimes a smooth streak 
will be found in the centre, and fur on each side. In 
such cases, the tongue is contracted and very red at 
its edges, which denotes high irritation or the approach 

22* 



254 THE TONGUE. 

of inflammation. All forms of inflammation of the 
ileum produce the symptoms of typhoid fever to a 
greater or less extent, and in febrile disease, of the 
small intestines, the nervous tremor varies in propor- 
tion to the morbid condition of the alimentary canal. 

If the irritation or inflammation extends to the colon 
in febrile disease, producing diarrhoea, the tongue 
will be found red at its point and edges, its centre 
being sometimes furred and sometimes smooth; if 
internal congestion supervene, the tongue will assume 
a dark livid hue. In bilious remittent fever it pre- 
sents the various appearances seen in all grades of 
fever, owing to the irregularity of the local seat of the 
disease. Hence the tongue may be smooth and 
glossy in one case, and red and dry in another, while 
in a third it may have a coat of bilious fur, and in a 
fourth a black, dry, rough coat at the centre, with the 
edges red and chapped so as to bleed. 

In the forming stage of true typhus fever, the ap- 
pearance differs from that of simple continued, or 
remittent fever, when the local seat of each is in 
the small intestines, — the white coat being thicker 
and more slimy; which, as the disease progresses, 
becomes brown, dry, and black, whilst in the con- 
tinued or remittent forms, there is not the regularity 
as in typhus. In true typhoid fever, the fur and 
color are various ; the coats are frequently thrown 
off, leaving the organ with different appearances, as 
before stated. But in all grades of fever, where the 
tongue has a red purple hue on its edges and under 
surfaces, it is an evident mark of secondary conges- 
tion, produced from high irritation or inflammation. 
In cholera such appearance was not present until after 



THE TONGUE. 255 

the system had reacted and established inflammation, 
although in this disease the most extensive congestion 
prevails. 

The tongue, in secondary fevers arising from wounds, 
contusions, &c, is variable, in accordance with the 
locality and extent of the injury. Where the scalp is 
wounded, establishing morbid vascular action, the 
tongue will be covered with a thick white fur in the 
onset, which will assume a bilious character in a few 
days, owing to the influence which wounds of the 
scalp produce upon the liver ; but in wounds of other 
parts of the system, the thick white fur will vary from 
a clammy to a dry condition. In inflammation of the 
brain or its meninges, the tongue is contracted and 
pointed, and the fur of a bilious order. In all forms 
of fever where congestion supervenes so as to produce 
stupor, it is relaxed and expanded. In catarrhal affec- 
tions and scarlatina, the papillae may be seen pro- 
truding through the white fur, of a florid color; in 
catarrhal cases, the tongue may become smooth and 
red, but in scarlatina it rarely presents this appear- 
ance. 

In sub-acute diseases located in either of the cavi- 
ties, the appearances of the tongue vary in accordance 
w T ith the organ affected, and the extent of the affection, 
and condition of the secretions. In dyspepsia the 
tongue is generally coated on its back portion, with a 
heavy fur varying in color from a darkish white, to a 
yellow ; but in mild cases it is only slightly coated, 
and in proportion to the chronic lesions of the different 
parts of the alimentary canal, it varies in appearance, 
being sometimes red, livid, and smooth on its surface. 
If the liver be affected the fur is generally of a bilious 



256 THE TONGUE, 

character, and where the system becomes debilitated 
it has a relaxed flabby appearance, with a long fur in 
the centre and back portion. In chronic hepatic or 
gastro-enteric diseases, the far varies from white to 
yellow, and the contracted or relaxed appearance 
will vary in proportion to the irritability and tone of 
the system. In strumous habit the appearance must 
of necessity vary in proportion to the various stages 
and organs affected, so as to represent the alterations 
of the tongue as noticed by medical authors, under 
the acute and chronic forms, as all parts of the sys- 
tem are liable to be affected with the disease, giving 
rise, in the inflammatory stage, to the appearance 
of fur and other alterations as observed in the dif- 
ferent stages of febrile disease ; with the exception, 
that the tongue is found more uniformly relaxed, 
paler and more tumid. Where the disease termi- 
nates in tubercular phthisis, it generally retains its 
natural appearance, until the mucous coat of the sto- 
mach and bowels participate in the morbid action, 
when the tongue is smooth and soft, the result of 
general debility. The same appearance of the organ 
is produced from psoas abscess, white swelling, or any 
excessive drain from the system, which should admon- 
ish us in febrile disease, that debility is in combination 
with febrile lesions produced from inflammation, irri- 
tation or functional derangement. In a general debili- 
tated condition of the system, produced from deranged 
functions, as in chlorosis, a very different appearance 
of the tongue presents itself, which is pale, tumid, 
with enlarged papillse, and as the debility advances, 
the organ becomes paler, more flabby, and eventually 
smooth. Hence our diagnosis must be made from a 



THE TONGUE. 257 

wide sphere of morbid changes ; in some cases from 
local causes, in others, from general defects — such as 
inherited diseases, functional derangements, inflamma- 
tions and organic lesions. It is known that the most 
prominent marks are frequently delusive, from the fact 
that the affection is not always uniform. Many dis- 
eases that appear to be of a general character, are 
found to have their origin from some obscure local 
affection. In such cases the diagnosis can only be 
formed by taking into consideration the predisposing 
and exciting cause, and by watching the changes in 
the secretions produced by remedial agents. There- 
fore there is but one source to make out a safe and 
reliable diagnosis. This must be made by contrasting 
the healthy actions of the organism, and the morbid 
changes produced from surrounding causes. Those 
who expect, or hope to profit by correct diagnosis, 
must make themselves acquainted with the organiza- 
tion of man, and the symptoms that are likely to arise 
from the morbid action of the different systems com- 
posing the organism, together with the condition of the 
mental faculties, the tongue, skin, countenance, urine, 
expectorations or exhalations from the lungs, and from 
the alvine discharges. This acquaintance, with a care- 
ful exploration of the organs of the chest and abdomen, 
is necessary to form a correct diagnosis. 



APPENDIX. 



The subsequent remarks would have been incor- 
porated in the essay on Fever, had they not been 
overlooked until too late. 

The theory and principles advanced in the preceding 
essays, founded upon the observations made in clinical 
practice, and upon a knowledge of the anatomical 
arrangements of the circulating and nervous systems, 
their ultimate radicals terminating upon the two tegu- 
mentary surfaces, and of the tendency of the solids 
and fluids to gravitate, most clearly prove that the 
God of nature has wisely arranged, for their protec- 
tion, the various organs of the human system, agree- 
ably to their importance and influence in health and 
disease. The brain, spinal marrow, with the organs 
of the chest, we find, are securely protected ; next are 
the organs of the pelvis and abdomen, which although 
equally important, would appear but slightly protected ; 
but when minutely examined, it will be found that where 



APPENDIX. 259 

they are liable to injury from concussion, they are 
enclosed by the diaphragm and ribs. Where they are 
slightly protected by the muscular parietes they have 
great mobility, and are less subject to injury from the 
accidents that are common to all. Hence, from their 
anatomical arrangement, it is manifest, that all the 
delicate parts of the system are equally protected, and 
secured against the casualties that might interfere 
with their harmonious action. 

From such provisional protection is it not reason- 
able to suppose, that provision is also made for the 
protection and preservation of each part, separately 
and singly. The capillary vessels and nervous termi- 
nations, are abundantly supplied with the necessary 
protective principle, in their susceptibility and con- 
tractility, which enables them to withstand the effects 
of morbific agents, which make their impressions 
through the external or internal tegumentary systems, 
by absorption or otherwise, which is manifest from the 
physiological effects of medicinal agents; and as it is 
admitted that all agents; whether therapeutical or 
morbific, when brought in contact with the living sys- 
tem, make a local impression, from which is estab- 
lished an exalted or diminished action of the physio- 
logical functions, according to the properties of the 
agent, or nature of the morbific cause. This is 
manifested in the vital resistance that the system is 
capable of making, to free herself from the offending 
cause, be that what it may. Hence it is in proportion 



260 APPENDIX, 

to the vital susceptibility of the system, that physiolo- 
gical or pathological effects are produced by medicine ; 
and as it is evident that medicinal agents act favorably 
upon one set of vessels or organs, while they derange 
the functions of another set by exalting or diminishing 
their action ; thus it is by observing the laws in favor 
of life and health, that the practitioner is capable of 
determining the effect of remedial agents in the treat- 
ment of disease. In a similar manner the effect of 
the morbific agents is discovered, in the diminished 
power of vitality to reject, or free herself from the 
cause, which had gained the ascendency over the re- 
sisting force. 

Again, when vitality is inadequate, we find in some 
cases that morbid action is confined to a certain part 
of the system where the disease becomes local, or if a 
barrier be thrown around the offending cause to check 
its irritating effect, as is wonderfully displayed in the 
bite of a rabid animal. In this case, we find the 
wound closed, and the disease remains undeveloped for 
months, until the premonitory symptoms are displayed 
in an elevated, tumid appearance of the cicatrix, and 
pain in the course of the nerves, with marks of 
inflammation of the part first affected, which proves 
conclusively, that the vital resistance had for a time 
checked the virus within the vicinity of the wound, 
to prevent its specific influence upon the system. 
But from the fluidity of the virus, the barrier is pene- 
trated, and hydrophobic symptoms established. Where 



APPENDIX. 261 

the cause is derived from a musket ball, the barrier 
established by nature would not only envelope, but 
exclude it from the sphere of vital action. But not so 
in the bite of the rabid animal ; the old wound being 
the part that admonishes the patient of the approach- 
ing evil. The cicatrix becoming an open foul ulcer, 
is conclusive evidence that any poison, by nature's 
protecting system of vessels, is resisted for a time 
by the vital influence of the circulating and ner- 
vous systems at their terminating extremes. By the 
vital susceptibility of these extremes, the medicinal 
agents change their action, so as to give a salutary 
effect when directed in accordance with the nature of 
the morbid action to be overcome ; but if the vital 
powers of the two tegumentary systems are below the 
point of susceptibility, the medicinal agent is inert. 
Consequently, it is obvious that the favorable action 
of medicine is a vital effort on the part of nature to 
free herself from the remedy administered for the cure 
of disease. 

When we take a survey of the various theories 
from the time of Hippocrates, with the modifications 
by Galen, Celsus, Sydenham, Boerhaave and Stahl, 
we find the Humoral pathology the basis of medical 
faith, until the appearance of the nervous pathology, 
advanced by Hoffman and Cullen. The former has 
the credit of first calling the attention of the profes- 
sion from the fluids to the solids. Hoffman based his 

theory upon the nervous system as being the first 

23 



262 APPENDIX. 

impressed by morbific agents, establishing spasm 
of the capillaries ; but Cullen was the perfecter of 
this new theory, to the overthrow of humoralism. 
Brown's theory advanced in opposition to Cullen, was 
an excessive or deficient excitement. Dr. Darwin 
embraced Brown's theory, with his ingenious addition 
and explanation by sympathy, which, in many par- 
ticulars, have continued, with slight additions or 
variations, to the present time. During these ages, 
to the time of Clutterbuck and Broussais, fever was 
recognized as a general disease ; but these three, with 
Bullard, considered fever the consequence of irrita- 
tion or inflammation. Dr. Southwood Smith, extends 
his theory to a succession of occurrences produced 
By various causes. First, on the nerves; secondly, 
on the circulation; thirdly, on the secretory and 
excretory systems. Thus a disposition to return to 
the theory of the fluids, is manifest, especially from 
the writings of Drs. Stevens and Stokes of Dublin, 
and Dr. Burne, of London. Again : when we examine 
in connection, the theories of American authors — such 
as Drs. Chapman, Eberle, Jackson, Dunglison, Wood, 
and others, can it be doubted that a large majority of 
them base their theories upon the changes produced by 
morbific and medicinal agents upon the terminating 
extremes of the nervous and circulating systems? 
These theorists in their turn, have swept off a certain 
amount of rubbish from, and added new lustre to our 
progressive science. It is manifest that the ancient 



APPENDIX. 263 

and modem fathers of the science, also, have been 
influenced in their various theories from the changes 
they have observed in these two systems, as, whilst 
these vessels and nerves retain their vitality they 
resist the introduction of the fluid not congenial 
with their natural functions; and by this inherent 
endowment in the net-works of the blood-vessels 
and nerves, the vital machine is protected against 
the deleterious influence of opposing elements, and 
by its susceptibility to impressions from remedial 
agents, is enabled to throw off disease. 

When the organization of the vital laboratory, 
contained within the abdomen and chest for the man- 
ufacture of the blood, and the laws of the animal 
functions, normal and deranged, are clearly under- 
stood ; and when it is known what depurating organs 
should be checked or incited, and what are the thera- 
peutical indications, which nature demands, then man 
need not be hurried off by functional derangement, 
but may live to the age allotted by his Creator. 



3477 



